Ascites
Ascites is the abnormal collection of fluid in the abdominal cavity, most often as a result of chronic liver disease. This fluid is outside of the intestines and collects between the abdominal wall and the organs within. In extreme cases, the abdomen expands outward and the intestines actually begin to float within this "lake" of fluid.

CAUSES OF ASCITES
Advanced liver failure accounts for the majority of cases, but about 20% of patients with ascites have a cause other than liver disease. These may be secondary to heart failure, kidney disease, or cancer. Rarely, ascites is due to pancreatic disease, a severely underactive thyroid, malnutrition, or tuberculosis.
Still liver disease is the most common cause. There are many types of liver disease, but most are due to excessive alcohol consumption or chronic hepatitis infection. When people have liver disease for a long period of time, healthy liver cells die and gradually replaced by scar tissue. The word "cirrhosis" implies that the liver has largely been replaced by "scar tissue". This scar tissue changes the smooth liver surface into lumps and nodules distorting the normal anatomy and disrupting the blood flow out of the liver. The heart continues to pump blood through the liver with each heartbeat. If the blood cannot flow freely outward, there is an imbalance and excessive pressure builds up in the liver tissue. This is called portal hypertension. In simplistic terms, this pressure imbalance causes the surface of the liver to "weep" fluid into the abdominal cavity which accumulates causing ascites.

SYMPTOMS
In mild cases, there are usually no symptoms. As more fluid accumulates, the abdomen begins to swell. There may be complaints of loss of appetite, frequent heartburn, fullness after eating, or abdominal pain. Eventually, there is marked distention of the abdomen - resembling the third trimester of pregnancy. This may cause low back pain, changes in bowel function, and fatigue. During the day, gravity may carry some of the fluid down into the scrotum or legs causing swelling, or edema. Initially, the swelling may subside overnight. As the condition worsens, however, the swelling may extend up the leg and be present day and night. As more fluid accumulates, it may spread up into the chest cavity (pleural effusion) and cause difficulty breathing.

DIAGNOSIS
The diagnosis of ascites can usually be made with history and physical exam. The diagnosis can be confirmed with ultrasound or CT scan. An ultrasound of the abdomen is often first chosen since it is a simple, non-invasive test, and readily available. Ultrasound is a very sensitive technique and can detect as little as 100 cc (about 3 ounces) of ascites.
If presence of ascites is confirmed, a procedure called paracentesis can easily be performed to safely remove some or all of the fluid. This is a simple procedure in which a needle is passed through the abdominal wall directly into the fluid collection. In this way, a sample of ascitic fluid can be obtained for laboratory analysis. Performed with a local anesthetic to numb the skin, abdominal paracentesis is usually a painless procedure. The risk of complications is quite low - less than 1/1000. These are most often minor, such as a bruise at the site of puncture, but may include internal bleeding, and inadvertent puncture of the intestines. Once the fluid has been obtained, it is sent to the laboratory for analysis.

Treatment
Ascites is not actually a disease, but a symptom. The proper treatment depends upon the underlying cause. If infection, cancer, or heart failure is the cause, the treatment is directed appropriately to the underlying problem. However, in the majority of patients, ascites is a sign of advanced liver failure, or cirrhosis of the liver, for which there is no medical cure. Treatment of ascites does not improve survival rates. Rather, the goal of treatment is to improve symptoms by reducing the amount of fluid in the abdomen. The mainstay of treatment includes:
1. Avoid further liver damage - Patients who drink alcohol must stop all alcohol consumption. The use of drugs that damage the liver must be avoided - such as high doses of Tylenol.
2. Dietary sodium restriction - Patients must learn that it is not too much water intake that perpetuates the accumulation of ascitic fluid in the abdomen, but rather an abnormal retention of sodium (salt) within the body. Thus, sodium restriction, not fluid restriction, is the mainstay of treatment. Dietary sodium intake is usually restricted to less than 2000 mg per day. Stricter sodium restriction can accelerate fluid and weight loss. In most patients, this restriction of sodium results in a drop of sodium levels in the blood (hyponatremia). This does not usually cause any symptoms, but when hyponatremia is severe (blood sodium less than 120), the patient must also be instructed to also limit intake of water and other fluids.
3. Diuretic therapy ("Water Pills") - Sodium restriction may be the mainstay of treatment, but in most cases of ascites, this alone is not effective. Most patients must also take a daily dose of medications called diuretics, or "water pills." These medications cause increased urine production and help the body excrete extra sodium and water through the kidneys. Common medications include spironolactone (Aldactone), triamterene (Dyrenium), furosemide (Lasix).
4. Therapeutic paracentesis - The same technique used to obtain a sample of ascitic fluid for testing can also be used to withdraw larger amounts of fluid. This is called a therapeutic or "large volume" paracentesis and is usually restricted to patients with ascites who do not respond to other forms of treatment or in patients with massive ascites. It is not uncommon for these individuals to have as much as 3 gallons of excess fluid in their abdominal cavity.
5. Monitor Progress - During treatment, it is important that patients undergo careful monitoring by their doctor with periodic measurements of body weight and blood tests. This is especially true in patients taking diuretics which may cause reduced kidney function and changes in the blood levels of sodium and potassium. The rate of fluid loss varies. When the lower legs are swollen, treatment can be more aggressive, but once the edema is gone, the goal slows to about 1 pound of weight loss a day. In the absence of edema, more rapid fluid loss can result in dehydration and kidney failure.

6. Refractory Ascites - About 10% of patients with cirrhosis and ascites will not respond to conventional therapy. These cases are considered to be intractable, or refractory to treatment. Refractory ascites is defined as fluid overload that does not respond to a sodium-restricted diet and high-dose diuretic therapy (e.g. 400 mg of spironolactone and 160 mg of furosemide daily). These patients may require repeated large volume paracenteses at intervals of 2 - 4 weeks. Refractory ascites is associated with a poor prognosis.

7. TIPS – Transjugular Intrahepatic Portosystemic Shunt is performed in some patients with refractory ascites. It is essentially a permanent metal stent placed by a radiologist within the liver. This is carried out through a catheter placed into the jugular vein in the neck. It usually is done with monitored anesthesia and takes less than an hour. This procedure is highly effective in reducing the rate of ascites fluid accumulation. Unfortunately, 30 -50% of patients may experience complications, including worsening of hepatic encephalopathy (confusion).
COMPLICATIONS
1. Spontaneous Bacterial Peritonitis (SBP) - Ascites fluid composition is fertile for growth of bacterial pathogens. When the fluid becomes infected, the lining of the abdominal cavity becomes inflamed (called peritonitis). Bacterial peritonitis is a potentially life threatening infection if gone untreated. Symptoms of peritonitis include abdominal pain and fever. Antibiotics are usually effective at eradicating the infection. After an episode of peritonitis, antibiotic prophylaxsis may be recommended to prevent another infection.

2. Hepatorenal syndrome- This name refers to kidney failure that sometimes develops in patients with end-stage liver disease. This may happen suddenly or as a slowly progressive process. Treatment usually involves stopping diuretic therapy, an intravenous fluid challenge, and a search for a reversible cause such as dehydration or infection. Rapid kidney failure in cirrhotic patients with ascites is associated with a mortality rate of over 90% if liver transplant is not performed.

What is Autoimmune Hepatitis?
Autoimmune hepatitis or autoimmune chronic hepatitis is a syndrome consisting of progressive inflammation of the liver that has been identified by a number of different names, including autoimmune chronic active hepatitis (CAN), idiopathic chronic active hepatitis, and lupoid hepatitis. The reason for this inflammation is not certain, but it is associated with an abnormality of the body's immune system and is often related to the production of antibodies that can be detected by blood tests.
Autoimmune hepatitis was first described in 1950 as a disease of young women, associated with increased gamma globulin in the blood and chronic hepatitis on liver biopsy. The presence of antinuclear antibodies (ANA) and the resemblance of some symptoms to systemic lupus erythematosus. (SLE) led to the label - lupoid hepatitis. It later became evident that this disease was not related to SLE. The disease is now called autoimmune hepatitis.
What are the Symptoms?
The typical patient with autoimmune hepatitis is female (70%). The disease may start at any age, but is most common in adolescence or early adulthood. Blood tests identify ANA or smooth muscle antibodies (SMA) in the majority of patients (60%). More than 80% of affected individuals have increased gamma globulin in the blood. Some patients have other autoimmune disorders such as thyroiditis, ulcerative colitis, diabetes mellitus, vitiligo (patchy loss of skin pigmentation), or Sjogren's syndrome (a syndrome that causes dry eyes and dry mouth). Other liver diseases such as viral hepatitis, Wilson's disease hemochromatosis, and alpha- I -antitrypsin deficiency should be excluded by appropriate blood tests, and the possibility of drug-induced hepatitis is ruled out by careful questioning.
The most common symptoms of autoimmune hepatitis are fatigue, abdominal discomfort, aching joints, itching, jaundice, enlarged liver, and spider angiomas (tumors) on the skin. Patients may also have complications of more advanced chronic hepatitis with cirrhosis, such as ascites (abdominal fluid) or mental confusion called encephalopathy. A liver biopsy is important to confirm the diagnosis and provide a prognosis. Liver biopsy may show mild chronic active hepatitis, more advanced chronic active hepatitis with scarring (fibrosis), or a fully developed cirrhosis.
How is Autoimmune Hepatitis Treated?
The 10-year survival rate in untreated patients is approximately 10%. The treatment of autoimmune hepatitis is immunosuppression with prednisone alone or prednisone and azathioprine (Imuran). This medical therapy has been shown to decrease symptoms, improve liver tests, and prolong survival in the majority of patients. Therapy is usually begun with prednisone 30 to 40 mg per day and then this dosage is reduced after a response is achieved.
The standard dosage used in the majority of patients is prednisone 10-15 mg per day, either alone or with azathioprine 50 me per day. Higher doses of prednisone given long-term are associated with an increase in serious side effects, including: hypertension, diabetes, peptic ulcer, bone thinning, and cataracts. Lower doses of prednisone may be used when combined with azathioprine.
The goal of treatment of autoimmune hepatitis is to cure or control the disease. In two thirds to three quarters of the patients, liver tests fall to within the normal range. Long-term follow-up studies show that autoimmune hepatitis appears more often to be a controllable rather than a curable disease, because the majority of patients relapse within six months after therapy is ended. Therefore, most patients need long-term maintenance therapy.
Not all patients with autoimmune hepatitis respond to prednisone treatment. Approximately 15-20% of patients with severe disease continue to deteriorate despite initiation of appropriate therapy. This is most common in patients with advanced cirrhosis on initial liver biopsy. Such patients are unlikely to respond to further medical therapy, and liver transplantation should be considered.

Barrett's Esophagus
Barrett’s Esophagus refers to a change in the lining of the esophagus from squamous epitherlium to intestinal metaplasia. This results in an increased risk of esophageal cancer. Because of this it’s termed a premalignant condition. It’s believed to be caused by chronic reflux of acid into the esophagus from the stomach (GERD).

INCIDENCE
Twenty percent or more of adults have chronic GERD and of these 10% to 15% will have Barrett's Esophagus, meaning that 1% to 2% of the American adult population potentially has this premalignant condition. Men and women with chronic severe reflux have over a 50% chance of having Barrett's Esophagus. Overall, only about 0.5% per year of individuals with Barrett's Esophagus will go on to develop esophageal cancer, but this rate is 40 times higher than normal. Considered an oddity until the 1970's, the incidence of esophageal cancer has increased rapidly in the past 30 years and is now the fastest rising incidence cancer in adults. Esophageal cancer seems to affect men more than women.

SYMPTOMS
There really are no symptoms of Barrett's itself, but most patients have a history of long standing acid reflux and complain of heartburn or indigestion, occurring at least two times a week. Other symptoms may include: difficulty swallowing food, waking up at night because of heartburn, persistent unexplained cough, or hoarseness. If you have these symptoms, you should be checked for Barrett's. Unfortunately, some patients with Barrett's have very little heartburn and no warning, even though they have significant damage.
DIAGNOSIS
Endoscopy and biopsy of the lining of the esophagus is currently the most accurate way to make the diagnosis of Barrett’s Esophagus. Barrett's cannot be diagnosed by blood tests or x-rays.
TREATMENT
The first goal of treatment is to stop acid reflux and prevent further damage from occurring. This can usually be accomplished with daily doses of medications such as Prilosec, Prevacid, Aciphex, Protonix, and Nexium which markedly reduce your production of stomach acid. Treatment relieves symptoms and may also reduce the risk of forming a stricture, a ring of scar tissue which may cause problems swallowing. You should know that successful treatment of the acid reflux does not cure the Barrett's. Even if symptoms are well controlled, the cancer risk remains and periodic endoscopy examinations every 1 – 3 years is recommended.

PATHOLOGY
Biopsies taken at the time of endoscopy are sent for histopathologic examination by a Pathologist. The main thing we ask the Pathologist to look for is "dysplasia." Dysplasia is a precancerous change (not cancer yet) which usually occurs before cancer ever develops. It can be thought of as an early warning signal and is often classified either as low grade or high grade dysplasia. Low grade dysplasia is seen most often and is less cause for concern. In this instance, reflux must be controlled and surveillance may need to be more frequent but there is no need for radical change in therapy. Over time, dysplasia may progress from low grade to high grade, then sometimes to cancer. If high grade dysplasia is found, the risk of cancer is much greater. Patients with high grade dysplasia need to be rescoped at more frequent intervals and additional biopsies obtained. If high grade dysplasia persists, there is a high risk of progression to cancer. In this circumstance, more aggressive treatment is needed. This involves surgery to remove part of the esophagus which contains the abnormal area of Barrett's, even if a definite cancer is not found. The whole idea is to do something before cancer develops.

SURGICAL MANAGEMENT
There are two types of surgery performed in cases of Barrett's. If no dysplasia is present and symptoms of acid reflux do not respond to intensive medical therapy, surgery may be necessary to retighten the loosened lower esophageal sphincter, thus preventing further acid damage. This operation does not remove the area of Barrett's which still must be periodically rebiopsied with endoscopy. In the past, this procedure required open surgery with a full incision and a prolonged recovery period. Newer laparoscopic techniques now allow a much simpler procedure with several mini-incisions and a shortened recovery period.

ALTERNATIVE MANAGEMENT
There are several “minimally invasive” techniques being studied to treat Barrett’s Esophagus. These include photodynamic therapy (PDT), thermal ablative therapy, and endoscopic mucosal resection. Each technique has been shown to be a potentially viable treatment of this condition, however, they are not widely available, and primarily being performed within the context of research protocols.

What Is Celiac Disease?
Celiac disease is a digestive disease that damages the small intestine and interferes with absorption of nutrients from food. People who have celiac disease cannot tolerate a protein called gluten, which is found in wheat, rye, barley' and possibly oats. When people with celiac disease eat foods containing gluten, their immune system responds by damaging the small intestine. Specifically, tiny fingerlike protrusions, called villi, on the lining of the small intestine are lost. Nutrients from food are absorbed into the bloodstream through these villi. Without villi, a person becomes malnourished - regardless of the quantity of food eaten.
Because the body's own immune system causes the damage, celiac disease is considered an autoimmune disorder. However, it is also classified as a disease of malabsorption because nutrients are nor absorbed. Celiac disease is also known as celiac sprue, nontropical sprue, and gluten-sensitive enteropathy.
Celiac disease is a genetic disease, meaning that it runs in families. Sometimes the disease is triggered-or becomes active for the first time after surgery, pregnancy, childbirth, viral infection, or severe emotional stress.
What Are the Symptoms?
Celiac disease affects people differently. Some people develop symptoms as children, others as adults. One factor thought to play a role in when and how celiac appears is, whether and how long a person was breastfed - the longer one was breastfed, the later symptoms of celiac disease appear, and the more atypical the symptoms. Other factors include the age at which one began eating foods containing gluten and how much gluten is eaten.
Symptoms may or may not occur in the digestive system. For example, one person might have diarrhea and abdominal pain, while another person has irritability or depression. In fact, irritability is one of the most common symptoms in children.
Symptoms of celiac disease may include one or more of the following:

• Recurring abdominal bloating and pain
• Chronic diarrhea
• Weight loss
• Pale, foul-smelling stool
• Unexplained anemia (low count of red blood cells)
• Gas
• Bone pain
• Behavior changes
• Muscle cramps
• Fatigue
• Delayed growth
• Failure to thrive in infants
• Pain in the joints
• Seizures
• Tingling numbness in the legs (from nerve damage).
• Pale sores inside the mouth, called aphthus ulcers.
• Painful skin rash, called dermatitis herpetiformis.
• Tooth discoloration or loss of enamel.
• Missed menstrual periods (often because of excessive weight loss).

Anemia, delayed growth, and weight loss are signs of malnutrition - not getting enough nutrients. Malnutrition is a serious problem for anyone, but particularly for children because they need adequate nutrition to develop properly.
Some people with celiac disease may not have symptoms. The undamaged part of their small intestine is able to absorb enough nutrients to prevent symptoms. However, people without symptoms are still at risk for the complications of celiac disease.

How Is Celiac Disease Diagnosed?
Diagnosing celiac disease can be difficult because some of its symptoms are similar to those of other diseases, including irritable bowel syndrome, Crohns disease, ulcerative colitis, diverticulosis, intestinal infections, chronic fatigue syndrome, and depression.
Recently, researchers discovered that people with celiac disease have higher than normal levels of certain antibodies in their blood. Antibodies are produced by the immune system in response to substances that the body perceives to be threatening. To diagnose celiac disease, physicians test blood to measure levels of antibodies to gluten. These antibodies are antigliadin, antiendomysium, antireticulin, and tissue transglutamase.
If the tests and symptoms suggest celiac disease, the physician may remove a tiny piece of tissue from the small intestine to check for damage to the villi. This is done in a procedure called a biopsy: the physician eases a long, thin tube called an endoscope through the mouth and stomach into the small intestine, and then takes a sample of tissue using instruments passed through the endoscope. Biopsy of the small intestine is the best way to diagnose celiac disease.

Screening
Screening for celiac disease involves testing asymptomatic people for the antibodies to gluten. Americans are not routinely screened for celiac disease. However, because celiac disease is hereditary, family members - particularly first degree relatives - of people who have been diagnosed may need to be tested for the disease. About 10 percent of an affected person's first degree relatives (parents, siblings, or children) will also have the disease. The longer a person goes undiagnosed and untreated, the greater the chance of developing malnutrition and other complications.
Treatment
Gluten free diet. For more information on this diet please see a dietician and/or refer to the related web links listed on our site.

Colon Cancer
If you have been told you have colon cancer, you are not alone. Unfortunately, cancer of the colon has become quite common in our society. Each year, about 155,000 Americans are diagnosed as having colon cancer. For unknown reasons, residents of urban areas of Northern United States have an especially high risk. In fact, about 1 in 17 (6%) will develop cancer of the colon in their lifetime. Only lung cancer takes a greater toll. Colon cancer is a disease in which cancer cells are found in the tissues of the colon or rectum. Unfortunately, when colon cancer develops, there may be few, if any, warning symptoms. In some cases, patients in our practice have had no warning signals or symptoms at all. The cancer can be in your colon for years before you notice any symptoms such as a change in bowel habits, rectal bleeding, abdominal pain, thin stools or unexplained weight loss.
CAUSES OF COLON CANCER
The cause is not fully understood. In most cases, colon cancer is triggered by a complex interaction of several different factors. But, regardless of the cause, we have learned that cancer of the colon first develops as a small non-cancerous growth, or polyp. Some people develop these little "mushroom-like" growths on the inner surface of the intestinal wall. These polyps can occur anywhere in the colon. There are no symptoms. As time goes on, these small polyps may become larger and larger. Eventually, an uncontrolled growth of malignant cells may occur within a polyp. Left untreated this cancer can penetrate surrounding tissues and spread to other organs. Certain factors may increase your risk of developing colon cancer. Your chance of developing colon cancer increases with age. Although young adults are occasionally affected, most colon cancer occurs in people after the age of 40. Contrary to some popular beliefs, both men and women are equally affected. Recently, scientists have identified a specific genetic mutation that may contribute to the risk of colon cancer. So, heredity is an important risk factor. Other factors such as insufficient fiber (roughage) in our diet may play a role in the formation of colon polyps and subsequent colon cancer.
DIAGNOSIS
Colon cancer can be detected by a variety of tests, including digital rectal exam, sigmoidoscopy, colonoscopy, or radiologic tests like CT scan or barium enema. Colonoscopy is the most accurate diagnostic test for colon cancer. All individuals age 50 and over should have a screening test for colon cancer. Some individuals may be at increased risk of colon cancer and they should be screened at an earlier age. These individuals include those with a family history of cancer of the colon, rectum, breast, or of the female organs; or those who have a history of ulcerative colitis (ulcers in the lining of the large intestines); or those with familial polyposis. When colon cancer is found, your prognosis (chance of recovery) and choice of treatment depend on the stage of your cancer (whether it is confined to the inner lining of your colon or if it has spread to other places) and your general state of health.
COLON CANCER STAGE
Colon cancer stage is determined at the time of surgery. Your doctor needs to know the stage of your disease to plan treatment. The Dukes system, developed many years ago, is widely used to classify colon cancer into several stages:
Pre-cancerous polyp - Small polyps are not usually cancerous, but will often become malignant as they grow larger over time. In most cases, polyps cause no warning symptoms. Occasionally, a small cluster of cancer cells are found in the top lining of a removed polyp (carcinoma-in-situ). No further treatment is usually needed.
Stage A Colon Cancer - This early cancer is localized to the inner smooth lining of the colon and has not spread through the muscular wall or outside the colon.

Stage B1 Colon - Cancer Cancer cells have invaded the muscular wall but have not broken through.
Stage B2 Colon - Cancer Cancer cells have invaded the muscular wall and have broken through, but they have not yet gone into the lymph nodes.
Stage C1 Colon - Cancer Cancer cells have broken through the outer protective covering and spread to nearby lymph nodes, but have not yet spread to other parts of the body. 1 - 4 lymph nodes are involved.
Stage C2 Colon - Cancer Cancer cells have broken through the outer protective covering and spread to nearby lymph nodes, but have not yet spread to other parts of the body. 5 or more lymph nodes are involved.
Stage D Colon Cancer - Cancer has spread to other parts of the body. Most often the liver is involved.
Recurrent Colon Cancer - Recurrent disease means that the cancer has come back (recurred) after it has been treated. It may come back in the colon or in another part of the body. Recurrent cancer of the colon is often found in the liver and/or lungs.
Average 5 Year Survival
Stage A 95%
Stage B1 80%
Stage B2 60%
Stage C1 60%
Stage C2 30%
Stage D < 5%
TREATMENT OVERVIEW
There are treatments for all patients with cancer of the colon. The primary goal of therapy is to cure. If cure is not possible, treatment is often still possible to achieve long term control of the illness and to manage the symptoms associated with cancer. Three kinds of treatments are available:

• surgery - taking out the cancer.
• radiation therapy - using high-energy x-rays to kill cancer cells.
• chemotherapy - using special drugs to kill cancer cells.

Your doctors will decide which of these three treatments is best in your particular case.
Surgery
Surgery is the most common treatment for all stages of cancer of the colon. Surgery is an operation. The goal of surgery is to remove the part of the colon affected by cancer. Most patients express a fear that they will have to "wear a bag" (colostomy) after colon cancer surgery. In fact, most patients do not need a colostomy pouch after surgery. Of course, surgery requires hospitalization and general anesthesia. After making an abdominal incision, the surgeon takes out the cancer and a small amount of healthy tissue around it. The healthy parts of the colon are then sewn together (anastomosis) with stitches or metal staples. The surgeon may also take out lymph nodes near the intestine and look at them under the microscope to see if they contain cancer. Sometimes the colon cannot be sewn back together. Then, the surgeon makes an opening (stoma) on the outside of the abdomen for waste to pass out of the body, a colostomy. Sometimes, a colostomy is only needed until the colon has healed, and then it can be reversed. However, in about 15% of cases the cancer is located very close to the end of the rectum. In this case, the surgeon must take out the entire rectum to remove all of the cancer. Then, the colostomy is permanent. If you have a colostomy, you will need to wear a special bag to collect body wastes. This special bag, which sticks to the skin around the stoma with a special glue, can be thrown away after it is used. This bag does not show under clothing, and most people take care of these bags themselves.

Radiation Therapy
Radiation therapy uses high-energy x-rays to kill cancer cells and shrink tumors. Radiation may come from a machine outside the body (external radiation therapy) or from putting materials that contain radiation through thin plastic tubes (internal radiation therapy) in the intestine area for a short time. Radiation can be used alone or in addition to surgery and/or chemotherapy. To protect healthy cells, special lead shields are often used. The person who gets radiation treatment is not radioactive during or after treatment and posses no risk to others. Although radiation treatment is painless, it can cause side effects such as tiredness, diarrhea, skin rash, and nausea.

Chemotherapy
Chemotherapy uses special drugs to kill cancer cells. Chemotherapy may be taken by pill, or it may be put into the body by a needle in a vein. Chemotherapy is called a systemic treatment because the drug enters the bloodstream, travels through the body, and can kill cancer cells outside the colon. If your doctor removes all the cancer that can be seen at the time of the operation, you may still be given chemotherapy after surgery to kill any cancer cells that may be left behind. Chemotherapy given after an operation to a person who has no remaining cancer cells that can be seen is called preventative, or adjuvant chemotherapy.
TREATMENT BY STAGE
Treatments for cancer of the colon depend on the stage of your disease, your age, and your general health. Your doctor will recommend treatment that is considered standard based on its effectiveness in a number of similar past cases as yours. But, each case is different. Not all patients are cured with standard therapy and some standard treatments may have more side effects than others. For these reasons, you should discuss the details with your doctor. If surgery alone is not sufficient, he may for a consult with a cancer specialist (oncologist). Pre-Cancerous Polyp - If found early, most colon polyps can be removed by outpatient colonoscopy without the need for major surgery. With mild sedation, the procedure is usually painless. Most patients are back to work in a few days. Occasionally, a few cancer cells are found in the tip of the polyp after removal. If there is no involvement of the polyp's stem, colonoscopic removal of polyp is usually felt to be sufficient. However, larger polyps and those with invasive cancer, require an open surgical procedure. Stage A Colon Cancer - Treatment is usually surgery to remove the cancer. About 90% of patients with colon cancers discovered at this early stage can be cured by surgery alone. Stage B1-2 Colon Cancer - Treatment is usually surgery to remove the cancer. If your tumor has spread to nearby tissue, you may also receive adjuvant chemotherapy or radiation therapy following surgery. Stage C1-2 Colon Cancer - Treatment is usually surgery to remove the cancer often followed by chemotherapy. Radiation therapy is sometimes also used. Clinical trials are evaluating new combinations of chemotherapy drugs and radiation therapy. Stage D Colon Cancer - Your treatment may be surgery to remove the cancer or to make the colon go around the cancer so that it can still work. In some cases surgery is performed to remove parts of other organs such as the liver, lungs, and ovaries, where the cancer may have spread. Chemotherapy and radiation therapy may be used to help relieve symptoms and prolong survival. Recurrent Colon Cancer - If, after initial treatment, the cancer has come back (recurred) in only one part of the body, treatment may consist of another operation to take out the cancer. If the cancer has spread to several parts of the body, your doctor may give you either chemotherapy or radiation therapy. You may also choose to participate in a clinical trial testing new treatment programs. After colon cancer surgery, healing takes about 4 to 6 weeks. In the first few weeks, you must limit your physical activity. Since, the body uses much energy to heal itself; you can expect to tire easily. But don't be afraid to be active when you feel up to it - a proper amount of activity actually hastens healing. Don't lift anything heavy or strain yourself for at least 6 weeks, though. Then, you will be able to resume your normal activity and return to work. Once you have recovered from surgery, chemotherapy may be begun if indicated. This is usually within 6 weeks after surgery. "Chemo" is prescribed by your oncologist, and is frequently administered in the office. Each case is different. But on average, treatments are given over 6 to 12 months. This varies with each case and the patient's tolerance to treatment. Usually done as an outpatient, each visit takes about 2 to 3 hours. As with any potent therapy, side effects can be expected. Chemotherapy works mainly on rapidly dividing cancer cells. But healthy cells, especially those that divide rapidly, can be harmed as well. This may cause unwanted side effects which are unpleasant but don't last forever. Most side effects are mild and can be limited with your doctor's help. They will go away gradually after treatment is stopped. Your oncologist will work closely with your family doctor in planning your treatment plan, administering the "chemo," and following your response to treatment.
CANCER SURVEILENCE
Colon cancer can return at or near the site of original surgery, and it can spread to organs in other parts of the body. After initial therapy, a program of regular follow-up visits allows your doctors to evaluate your response to treatment and may help detect early recurrence of cancer. Patients treated for colon cancer also have a high risk of developing new colon polyps which could lead to another cancer in the colon. It is important for patients to be followed carefully, so that if these problems occur, they can be found and treated as early as possible. A surveillance program usually includes physical examinations, blood tests and colonoscopy examinations. X-rays may be requested. These exams are done most frequently in the first five years after surgery when the risk of recurrent colon cancer is the highest. Because this disease is often hereditary, it is also recommended that your blood relatives (brothers, sisters, and children) over the age of 40 consult with their physician about a program of periodic colon examinations. This may be lifesaving if a colon polyp is discovered and removed before cancer develops.

Colon Polyps and Cancer Prevention

Colon cancer is the leading cause of cancer deaths in nonsmokers. Only lung cancer is more deadly. This year we can expect about 134,000 new cases of colon cancer - 55,000 deaths. The good news is that it is surprisingly easy to significantly lower your risk of this common deadly disease.
Colon cancer is a malignant growth that occurs on the inner wall of the colon or the rectum. It is well recognized that colon cancer usually begins many years earlier as a small noncancerous growth called a polyp, which grows on the inner wall of the colon. Polyps arise from genetic mutations in the DNA of the cells that line the colon. All the risk factor for developing these genetic mutations are not known, but genetics probably plays an important role. Over time some polyps will grow larger until they develop into colon cancer. Although there are always exceptions, current data suggests that this malignant transformation is slow and may take 10 years or longer.
A colon polyp is an abnormal tissue growth which arises on the inner surface of the colon. The large intestine (aka colon) is 6 foot long and looks like a hollow pipe, with a ribbed inner surface. For multiple reasons, some individuals grow polyps, or small lumps of tissue, on the inner wall of the colon. There may be single or multiple polyps. Polyps are caused by gene mutations of the DNA in the cells that line the colon. All the causes of these mutations are not well understood. Colon polyps are found in one of two shapes. Polyps on stems or stalks look like mushrooms and are called pedunculated. When they are flat they are called sessile and sometimes more difficult to find and remove.
CANCER RISK
Colon polyps are important, since some may turn into colon cancer over time. While not every colon polyp turns to cancer, it is felt that almost every colon cancer begins as a small non-cancerous polyp. Fortunately, during colonoscopy these polyps can be identified and removed - thus preventing a possible colon cancer. If a polyp is large enough, tissue can be retrieved and sent for biopsy to determine the exact type of polyp.
DIFFERENT TISSUE TYPES OF POLYPS
There are basically 4 types of polyps that commonly occur within the colon:
1. Inflammatory - Most often found in patients with ulcerative colitis or Crohn's disease. Often called "pseudopolyps" (false polyps), they are not true polyps, but just a reaction to chronic inflammation of the colon wall. They are not the type that turns to cancer. They are usually biopsied to verify type.
2. Hyperplastic - A common type of polyp which is usually very small and found in the rectum. They are considered to be low risk for cancer.
3. Tubular adenoma or adenomatous polyp - This is the most common type of polyp and the one referred to most often when a doctor speaks of colon polyps. About 70% of polyps removed are of this type. Adenomas carry a definite cancer risk which rises as the polyp grows larger. Adenomatous polyps usually cause no symptoms, but if detected early they can be removed during colonoscopy before any cancer cells form. The good news is that polyps grow slowly and may take years to turn into cancer. Patients with a history of adenomatous polyps must be periodically reexamined.
4. Villous adenoma or tubulovillous adenoma- About 15% of polyps removed are of this type. This is a much more serious type of polyp that has a very high cancer risk as it grows larger. Larger sessile villous adenomas may require surgery for complete removal. Follow up depends on size and completeness of removal.
COLON CANCER RISK FACTORS
Family history of colon cancer is a well recognized risk factor. Most case of colon cancer (>75%), however, are not associated with any risk factors whatsoever. Despite a popular misconception, colon cancer is also an equal opportunity disease - men and women are equally affected. Most cases are diagnosed after the age of 50 and the risk increases with age. The most common symptom of colon cancer is no symptom at all. You could have a polyp, or even an early cancer, growing in your colon right now as you read this and feel perfectly fine. There are no symptoms such as pain, bleeding, or change in bowel habits to warn you - until it is too late. By the time that a colon cancer is large enough to change your bowel habits, it may already be too late. Left undetected, colon cancer eventually penetrates through the outer colon wall and spreads to other organs, most often lymph nodes and the liver. It has been well demonstrated that if colon cancer is caught in the earliest stages, the cure rate could be increased to 90%. Even better, it has been repeatedly shown that by detecting and removing colon polyps before they develop into cancer, colon cancer can be prevented. Most polyps can now be painlessly removed during a simple 20 minute outpatient "scope" procedure called colonoscopy. To decrease your risk of colon cancer, you need to have any colon polyps found and removed before they become cancerous.
COLON CANCER SCREENING
To reduce your personal risk, you should undergo an active program of periodic colon checkups, before you have symptoms - just as you would for routine mammograms and prostate exams. You must go see your doctor when you feel well. Here are three different situations that might arise:
1. If You Have Symptoms Screening programs for colon polyps and cancer are designed for patients who have no symptoms. If you have symptoms such as rectal bleeding, altered bowel habit, or have been found to have unexplained iron deficiency anemia or a positive test for hidden blood in your stool (Hemoccult), you need to see your doctor for a full investigation, not a screening exam.
2. Average Risk Individuals - No Symptoms Most people fit into this category. For those with no symptoms and no high risk factors, it is recommended that screening begin at age 50. At a minimum, this should include a 3-day Hemoccult card test for hidden blood in the stool every year and a flexible sigmoidoscopy, "short scope test," every 5 years. Recently, it has been shown that this regimen still misses up to 30% of colon cancer and even more polyps. This is why most professional health organizations - like the American Cancer Society - now endorse Colonoscopy as a primary screening method. There are three advantages to colonoscopy. First is higher accuracy since the entire colon is visualized. Second, with colonoscopy most polyps can be removed when found. Even better, if normal, screening colonoscopy need not be repeated as often.
3. High Risk Individual - While we are all at risk, some of us have a higher risk than others because of certain factors in our medical history. Those who fall into a high risk category should also be screened, but at an earlier age such as 40. The appropriate test should be chosen by your physician depending on the circumstances. Most often, a colonoscopy "full scope" exam is done.
High risk factors include:

• Personal history of colon polyps
• Personal history of colon cancer
• Ulcerative or Crohn's colitis
• Personal history of breast or uterine cancer
• Family history of colon cancer
• Family history of precancerous polyps If you fall into one of these high risk categories, it is even more important that you begin a regular screening program.

POLYP PREVENTION
There is no reliable way to prevent further colon polyps. However, the risk of polyps can be lowered somewhat by adding more fiber, extra calcium, and 400 micrograms (mcg.) of the vitamin folic acid to the daily diet. Low dose aspirin may also be protective. One study demonstrated a 40% drop in the incidence of recurrent polyps by taking an 81 mg baby aspirin daily. Interestingly, higher doses were less protective. But since polyps can not be reliably prevented, periodic colonoscopy exams are recommended.
COLON CANCER PREVENTION
If you have a history of adenomatous polyps, your risk of future polyps is about 60% - and there are usually no warning symptoms that colon polyps are present. The measures described above may be of benefit - but can't reliably prevent future polyps. With periodic colonoscopy exams, you can maximize your chances that any new polyp will be detected and removed before cancer cells develop. Rarely, a colon cancer may develop between colonoscopy exams. Fortunately, they are usually small and curable by surgery. Periodic colonoscopy can significantly reduce your risk of colon cancer. Ask your doctor when your next colonoscopy should be done.

GET YOUR COLON CHECKED!
Colon cancer is one of the most curable and preventable forms of cancer. When detected early, more than 90% of patients can be cured. Sadly, recent studies show that only about 12% of adults ever bother to have a colon examination. As an individual, you can dramatically reduce

your risk of getting colon cancer by having regular examinations before symptoms develop. Following the simple guidelines can keep you healthy to enjoy the good life you have worked so hard to create. Take charge of your health.

Constipation?

By any yardstick, constipation is a common problem, affecting about 1 in every 50 people. Even so, it's surprising to discover that this ailment accounts for about 2.5 million visits to physicians annually. And almost 100,000 individuals are hospitalized each year for what are described as constipation-related problems.
With that in mind, it's not surprising to see the number of ads for laxatives aimed at helping to keep us "regular." But what is regular? And what is constipation really? Some people will say their stools are too hard or dry, or that they have to strain to move their bowels. Others will note that they have infrequent bowel movements. The definition of constipation for many physicians, and the one used in clinical research, is having fewer than three bowel movements a week.
Nevertheless, individuals can and do vary on what is normal for them. So your bowel movements could be fine if you "go" as often as three times a day, and you don't necessarily have constipation if you go as infrequently as every fifth day. Certainly, the notion that one bowel movement every day is essential is pure fallacy.
Constipation seems to occur in some people more often than in others. Women are more prone than men, especially during pregnancy. Increased pressure on the bowel from the fetus, a decline in gut motility, and less physical activity all contribute to constipation at this time.
People older than 65 also are affected more frequently. Many factors combine to cause constipation: a general slowing down of bodily functions as one ages; poor nutrition, which might come about because of less money to spend on food, loss of a spouse, or lack of family or friends with whom to share meals; not drinking enough fluids; lack of physical activity; or taking certain medications. Other lifestyle factors or habits, in people of all ages, can lead to constipation. Irregular eating and drinking, as well as travel - whether for business or pleasure - are all potential reasons for constipation to occur.
A very common cause of constipation is overuse of laxatives. People who habitually take laxatives eventually become dependent on them. That means laxatives are taken in larger amounts and with greater frequency, until finally the small intestine and colon no longer work on their own and daily laxatives become the norm. This condition is known as a cathartic colon, or "lazy bowel."
Other drugs can also have a constipating effect, including pain relievers, aluminum-containing antacids, and iron supplements. Medications to control high blood pressure, antispasmodic drugs, and antidepressants are other possible "culprits."
Not to be overlooked as a factor in chronic constipation are dramatic changes in the American diet. A century or so ago, the average daily consumption of fiber was at least 40 grams. Today the daily average is about 10 grams. When you take a look at what we're eating today - lots of refined foods that contain fat, sugar, and calories, but not much fiber - it's easy to understand why. When the reduction in fiber intake is accompanied by a basically sedentary lifestyle, constipation is often the result.
Finally, when constipation is a chronic problem, it may indicate a serious underlying disease. Irritable bowel syndrome is one of the most common causes of constipation in the United States. Uncoordinated muscular contractions in people with IBS can delay the movement of bowel contents, leading to constipation. Other gastrointestinal disorders - for example, inflammatory bowel disease or hemorrhoids may produce an obstruction or narrowed passageway, or can cause painful elimination.
In other situations, hormonal disturbances, such as an underactive thyroid, can be the problem. Diabetics frequently suffer from constipation. Neurologic diseases such as stroke, multiple sclerosis, and Parkinson's disease, also are linked to constipation.
The good news is that constipation is not only treatable, but also preventable. In many cases, dietary changes are the answer.
What to Do About It
Prevention is the key word when it comes to constipation. For the most part, a balanced diet with an emphasis on fiber is the first line of defense. Drinking lots of fluids and making exercise part of your general routine also will help you stay regular.
Time is an important consideration that people often overlook when it comes to preventing constipation. Allowing time to "heed the call of nature" shouldn't be ignored. With busy schedules and hectic lifestyles, we sometimes rush ourselves or even try to postpone going to the bathroom until a more convenient time. Unfortunately, the latter habit may lead to a loss of our rectal reflexes.
For most people, the morning seems to be "their time." Perhaps it's drinking hot liquids or stimulants such as caffeine that is responsible for the urge to go. Whatever the reason, be sure to allow enough time to have a full and relaxed movement. If the feeling comes later in the day, give yourself the few minutes it takes at that time for an undisturbed visit to the bathroom.
If you notice any change in bowel habits that persists for several weeks, it's a good idea to see your physician. Sometimes, constipation is related to other conditions. If you think you're already eating a healthy variety of foods and drinking plenty of water, and yet you develop a constipation problem, a checkup is definitely in order.
Diet

Natural fiber is readily available in a variety of foods. And let's face it, food is a tastier way of reducing, if not eliminating, constipation than fiber laxatives. So what is fiber? And how much of it should we be eating each day?
Fiber is the part of plant foods we eat that is resistant to normal digestive processes. It is found in vegetables, fruits, whole grains, nuts, and seeds, and not at all in meat, milk, or other dairy products. Also referred to as bulk or roughage, fiber in your diet helps keep you regular. There are other great reasons to boost your daily fiber intake A high-fiber diet is a treatment for diverticulosis, a disorder in which the bowel wall folds outward and forms small pouches which can trap food and become infected. Fiber also may have a positive role in the management of high cholesterol and diabetes, and it may even reduce the risk of developing certain types of cancer.
Including more fiber in your diet goes way beyond bran cereals and prune juice. But don't overlook these foods - they're a good way to get a head start on your fiber quota first thing in the morning. A high-fiber diet is varied and contains a wide array of foods, including whole-grain breads and cereals, beans, lentils, vegetables, and fruits.
The recommended amount of fiber is about 20 to 35 grams per day. (Dietitians often base fiber requirements on the amount of calories consumed and figure 10 to 13 grams per 1,000 calories.) That is almost double the amount of fiber that most Americans actually consume now.

Dietary fiber is classified according to how soluble it is in water. Foods like oat bran, barley, lentils, carrots, plums, apricots, bananas, and pears contain soluble fiber. Soluble fibers are sticky and combine with water to form gels. They have a role in the function of the digestive tract, but seem to play a bigger part in reducing blood cholesterol and may reduce insulin needs in some diabetics.
Insoluble fiber is composed largely of cellulose and lignin - the chewy outer parts of seeds or fruit skins, husks, and peels. It is also found in wheat germ, dried peas and beans, cornmeal, millet, and apples. Insoluble fiber, especially wheat bran, is particularly effective in the treatment of chronic constipation. This type of fiber tends to act mainly as a bulking agent; that is, it absorbs large amounts of water and creates a soft, bulky stool. Stool weight is also increased, and the combined effect is to reduce the time it takes for digested food to move through the digestive tract. So you can see how it can be effective in the treatment of constipation. Regulating intestinal "transit time" means that, in some cases, fiber also can be effective in the treatment of diarrhea.
When you start on your fiber program, a few suggestions are in order. First, do it slowly. Fiber can produce gas and bloating, especially in the beginning. Try to spread your fiber intake throughout the day. Don't just load up on a big bowl of bran and fruit in the morning.
Second, drink lots of water. Remember that fiber works because of its ability to hold water. If there's not enough water around in your gut, the fiber will literally get stuck and produce severe constipation. A minimum of eight glasses of water a day is essential to keep that fiber moving along.
Other Factors

A regular exercise program also helps bowel regularity. It keeps the blood circulating and all systems "go." Exercise also contributes to overall good health and to a positive mental outlook, so the benefits of physical activity are numerous.
Biofeedback training may be of benefit. Sometimes excessive tension or inappropriate constriction of muscles contributes to constipation. There is evidence that after a few biofeedback sessions patients can learn to substitute normal relaxation of rectal muscles for the tightening or contracting they may have been doing inadvertently.
To be most effective, any changes you adopt should happen gradually. Be patient. It may take a few weeks for your body to adjust. Changes should not be disruptive; that way, there's a better chance they'll become an integral part of your life.
A Word about Laxatives
Laxatives can be used occasionally. But their use really should be a last resort. Dependence on, or overuse of, laxatives has its own problems. Muscles get lazy when they are artificially stimulated all the time (as with a laxative). Over time, muscle tension is reduced or lost. However, that cycle can be broken. If you are in that predicament, take heart. Reduce laxative use gradually and follow the suggestions below. In a couple of weeks, you should be doing fine on your own. Pregnant women should avoid taking any laxative unless it's recommended by their physicians. Increased consumption of fruits, vegetables, cereals, and grains, along with more water and physical activity, is the best solution during this time.
Several types of laxatives are available and work in a variety of ways. They include fiber, lubricants, emollient laxatives, and stimulant cathartics.
Fiber such as bran or psyllium is a bulk-forming agent. It swells, absorbs water, and helps to move digested foods through the intestinal tract and out of the body. Grandma's favorite standby, mineral oil, is an example of the lubricant type of laxative. However, mineral oil can also interfere with the absorption of calcium and fat-soluble vitamins (A, D, E, and K), so try to avoid it. Emollient laxatives are also known as stool softeners; for the most, part they are not too effective and are not recommended for long-term use. Stimulant cathartics—for example, senna, bisacodyl, and phenolphthalein - are frequently found in over-the-counter preparations. Check the label for ingredients in your brand. These compounds are not recommended for long-term use; yet physicians find that many people become dependent on them. If you think you're overusing stimulant cathartics now, taper them off gradually while you add more water and fiber to your diet.
Other Drugs for Constipation
Improvement in constipation has been reported with some medications. Misoprostol (Cytotec), a prostaglandin compound used to treat injuries of the stomach related to NSAID use, is known to cause diarrhea. Naloxone (Narcan), a treatment for patients needing to take narcotics on a chronic basis, may produce improvement in some constipated individuals. It should be noted that these drugs are not currently approved by the U.S. Food and Drug Administration (FDA) for use in treating constipation.
Summary
Speak to your physician if constipation is a serious problem for you. It's particularly important to have this discussion if you are overusing laxatives or think you may be becoming dependent on them. Finally, keeping a diary can be helpful. Note down when you get the urge to defecate, how much water you're drinking, what you are eating, and how much fiber you're getting. Observing the effects of your behavior will help you find your personal solution to constipation.
Some drugs that can cause constipation
Analgesics (pain relievers)
Antacid (calcium and aluminum)
Anticholinergics
Anticonvulsants
Antidepressants
Antihypertensives
Antiparkinsonian drugs
Diuretics
Iron supplements
MAO Inhibitors
Opiates
Psychoactive drugs
Fiber at a Glance
Here's a quick reference chart to show you foods that contain soluble and insoluble fiber. Note that some foods contain both types of fiber. Though you should have some of both kinds each day for your overall health, it's the insoluble fiber that works best in reducing constipation.
Insoluble Soluble
Wheat bran Oat bran
Corn bran Rice bran
Whole grains Chick peas
(wheatberries etc.)
Dried beans
(kidney, navy etc.) Sesame seeds
Canned beans All fruits and vegetables
especially apples
plumes, pears, carrots
Nuts and seeds
Most fruits and
vegetables especially
potatoes, broccoli,
parsnips

Fiber Supplement
No doubt you've seen a number of fiber supplements in the store, ranging from bran tablets to cellulose powders. They can, indeed, be effective in treating constipation. For some individuals, however, they can produce side effects like gas, bloating, nausea, and abdominal discomfort. That's because these products consist of a highly purified form of fiber. Before reaching for a can of fiber, however, first try to boost the fiber in your diet by increasing the amount of fruits, vegetables, grains, cereals, beans, and lentils you eat on a daily basis. You'll get an array of colors, tastes, and textures, as well as a lot more pleasure from eating wholesome foods along with it.

Quick Tips to Boost Your Fiber Intake
· Stir frozen vegetables into your favorite soup, sauce, or casserole. Broccoli and cauliflower in a tomato sauce, corn in chili, or mixed vegetables into chicken soup are just a few suggestions to get you started.
· Sprinkle some wheat germ over hot cereals, salads, or grain dishes.
· Order brown rice in Chinese restaurants.
· Toss cooked or canned (drained) beans into soups, salads, and pasta dishes.
· Use cooked lentils in rice pilafs, burger and meatloaf mixtures, and pasta sauces.
· Sprinkle frozen (and thawed) peas, broccoli, or corn onto pizza before baking.
· Add fresh and dried fruits to muffin and quick bread recipes.
· Save the pulp from your juicer and add to soups, sauces, and cake recipes.
· Try air-popped popcorn as a snack instead of pretzels or chips.
· Serve drained slices or chunks of canned fruit over cereals, slices of fat-free pound cake, or frozen yogurt.
Beyond Fresh: Fruit and Vegetable Fiber Bonuses
Most people are hooked on the notion that freshly picked fruits and vegetables are the best, and perhaps the only way to get the highest amount of fiber and nutrients. Fortunately, that's just not so. Sure, nothing beats a fresh, juicy peach in the middle of summer; and if you're lucky enough to live close to a farm, or have access to a farmer's market, chances are you're getting a high nutritional value. But it's time for everyone to take another look at canned and frozen fruits and vegetables to find out what they offer.
Variety is the cornerstone of good nutrition. In reality, a combination of canned and frozen fruits and vegetables offers the best and most convenient way to ensure practical, as well as tasty, nutrition. There are literally dozens of items from which to choose, and a variety of forms in which they are packed. It's time to let go of the notion that frozen or canned items are necessarily loaded with fat, sodium, and sugar, or that they are automatically less nutritious than their fresh counterparts. If you have any question, just take a look at some labels next time you're in the supermarket to see what's not in a lot of these foods.
Today, frozen fruits and vegetables are flash frozen at the peak of freshness within hours of harvest. This process helps to preserve nutrients.
In fact there have been several studies that show that frozen items actually contain as much, or more, nutrient value as raw produce. That's because it may take several days for the fresh food to be packaged and then shipped to the supermarket. Add a few more days of storage time in the refrigerator at home, and more nutrients are lost.
From a practical point of view, frozen and canned items are always ready to go. There's no cleaning, peeling, cutting, and trimming for you to do. Simply open the package or the can and add the contents to your favorite recipe. When using frozen items, I find it particularly helpful to buy them in plastic bags. They defrost faster, and it's easier to measure out a cup or two from a bag than it is to try to separate a solid block.
In terms of fiber content, corn, spinach, and peas rate especially high, as do the cruciferous vegetables such as Brussels sprouts, broccoli, bok choy, cauliflower, and collard greens. The latter are also rich sources of vitamin A. Though each of these vegetables is packaged individually, there are also many interesting frozen vegetable combinations that contain three or four different types of vegetables in the same bag. These make a great addition to pasta or rice for a quick and easy primavera dish, or you can toss them with lettuce for a five-minute salad.
Frozen and canned fruits shouldn't be overlooked either. Frozen berries are a great way to enjoy these summer treats all year long. They can be used for fruit purees to serve over desserts, blended with yogurt for healthy drinks, or tossed into muffin batters. Canned fruits offer good nutrition and good taste. Remember that canned fruits are now packed in natural juices as well as in traditional heavy syrups. Canned pears and peaches are especially high in fiber. You might add canned peaches to a fresh spinach salad, or toss canned pear slices with fresh berries for a stunning dessert.

Crohn's Disease?

Crohns disease is a chronic, recurrent inflammatory disease of the intestinal tract. The intestinal tract has four major parts: the esophagus, or foodpipe; the stomach, where food is churned and digested; the long, small bowel, where nutrients, calories, and vitamins are absorbed; and the colon and rectum, where water is absorbed and stool is stored. The two primary sites for Crohns disease are the ileum, which is the last portion of the small bowel (ileitis, regional enteritis), and the colon (Crohns colitis). The condition begins as small, microscopic nests of inflammation which persist and smolder. The lining of the bowel can then become ulcerated and the bowel wall thickened. Eventually, the bowel may become narrowed.
What Causes Crohns Disease?
After many years of intense research, the cause of Crohns disease is still unknown. One theory is that the condition is caused by an unidentified, slow-growing microorganism. The body's immune system, which protects it against many different infections, is also known to be a factor. In spite of the unknown cause, enormous understanding and knowledge currently exist about the disease and its treatment.
Who Develops Crohns Disease?
The condition occurs in both sexes and among all age groups, although it most frequently begins in young people. For unknown reasons, Jewish people are at increased risk of developing Crohns, while African Americans are at decreased risk.
Symptoms
The symptoms of Crohns disease depend on where in the intestinal tract the disorder first appears. When the ileum (ileitis) is involved, recurrent pain may be experienced in the right' lower abdomen. At times, the pain mimics acute appendicitis. When the colon is the site, diarrhea (which is sometimes bloody) may occur, as well as fever and weight loss.
When the inflammation is active, fatigue and lethargy appear. In children and young people there may be difficulty gaining or maintaining weight.
Diagnosis
There is no one conclusive diagnostic test for Crohns disease. The physician uses a series of tests to assess the patient's overall condition and then makes a diagnosis. The patient's medical history and physical exam are always helpful. Certain blood and stool tests are performed to arrive at a diagnosis. X rays of the small intestine and colon (obtained through an upper Gl series and barium enema) are usually required. In addition, a visual examination (sigmoidoscopy) of the lining of the rectum and lower bowel is usually necessary. A more extensive exam of the entire colon (colonoscopy) is often the best way of diagnosing the problem when the disease is in the colon.
What Are the Course and Complications of the Disease?
The disorder often remains quiet and easily controlled for long periods of time. Most people with Crohns disease continue to pursue their goals in life, go to school, marry, have a family, and work with few limitations or inconveniences. Some problems, however, can occur. Arthritis, eye and skin problems, and—in rare instances— chronic liver conditions may develop. The disease can occur around the anal canal. Open sores called fissures can develop, which are often painful. A fistula can also form. This is a tiny artificial channel that burrows from the rectum to the skin around the anus. In addition, when inflammation persists in the ileum or colon, narrowing and partial obstruction may occur. Often surgery is required to treat these problems. Cancer is not a worrisome outcome of Crohns disease, as it occurs only slightly more frequently among sufferers of the disease than in the general population.
Treatment
Effective medical and surgical treatment is available for Crohns disease. It is particularly important for the patient to maintain good nutrition and health, with a balanced diet, adequate exercise, and a positive, upbeat attitude.
Three types of medication are usually used in treating this disease:
1. Cortisone or Steroids—These powerful drugs provide highly effective results. Commonly, a high dose is used initially to bring the disorder under control. Then the drug is tapered to a low maintenance dose, to an alternate day schedule, or (hopefully) to cessation. This medicine is administered by pill or enema.
2. Anti-inflammation Drugs—sulfasalazine (Azulfidine), olsalazine (Dipentum), and mesalamine (Asacol, Rowasa, Pentasa) belong to a group of drugs called the 5-aminosalcylate group. These drugs are most useful in maintaining a remission, once the disease is brought under control. They are available in oral and enema preparations.
3. Immune System Suppressors—These medications suppress the body's immune system, which appears to be overly active and to perpetuate the disease in Crohns patients. The names of two of these commonly used medications are azathioprine (Imuran) and 6 MP (Purinethol). There are other potent immune-suppressing drugs that may be used in difficult cases.
4. Antibiotics—Since there is frequently bacterial infection along with Crohns disease, a wide assortment of antibiotics is available to treat this problem. One that is commonly used is metronidazole (Flagyl).
5. Biologics – Remicade (Infliximab) is the newest medication in the treatment armamentarium against Crohns disease. It is given as an IV infusion and is very effective at directly suppressing inflammation in the gut.
Diet and Emotions There are no foods known to injure the bowel. However, during an acute phase of the disease, bulky foods, milk, and milk products can increase diarrhea and cramping. Generally, the patient is advised to eat a well-balanced diet, with adequate protein and calories. A multivitamin and iron supplement may be recommended by the physician.
Stress, anxiety, and extreme emotions may aggravate symptoms of the disorder, but are not believed to cause it or make it worse. Any chronic disease can produce a serious emotional reaction, which can usually be handled through discussion with the physician.
Surgery
Surgery is commonly needed at some time during the course of Crohns disease. It may involve removing a portion of diseased bowel, or the simply draining an abscess or fistula. In all cases, the guiding principle is to perform the least amount of surgery to correct the immediate problem. It should be understood that surgery does not cure Crohns disease.
In Summary . . .
Most people with Crohns disease lead active lives with few restrictions. Although there is no known cure for the disorder, it can be managed with present treatments. For a few patients, the course of the disease can be more difficult and complicated, requiring extensive testing and therapy. Surgery sometimes is required. In all cases, follow-up care is essential to treating the disease and, hopefully, preventing or dealing with complications that may arise.

Fatty Liver Disease
Almost all the organs of the body contain some fat. Fat cells provide insulation, protection, and are an efficient way to store extra energy. After a typical meal, dietary fat is absorbed by the intestines and enters the blood stream which carries the fat directly to the liver. Normally, this fat is metabolized in the liver and converted to energy. If the amount of fat delivered is excessive, it is stored in the liver and other tissues. The normal liver contains about 5% fat. The rest of the liver is made up of liver cells called hepatocytes which do all the work of the liver. When the amount of fat in the liver exceeds 10%, healthy liver cells are replaced by fat cells. This condition is termed a fatty liver, or steatosis.
INCIDENCE
Recent surveys have shown fatty liver to be much more common than previously recognized. It now affects about 23% of adult Americans and has become the most common cause of abnormal liver blood tests in the US population.
RISK FACTORS
The typical patient is an older obese woman who may be diabetic, but fatty liver affects both sexes and may occur in those of normal weight. It is also quite common in those who consume excessive amounts of alcohol.
NATURAL HISTORY
There are two types of fatty liver - that seen in alcoholics and that which occurs in non-drinkers. It has been recognized for centuries that chronic alcoholism can cause progressive liver failure. The first stage of alcoholic liver disease is a fatty liver. At this stage, the damage is often reversible if the individual becomes totally abstinent. But, with continued drinking, liver disease progresses leading to cirrhosis. Liver cells die and are replaced by scar tissue. When excessive scar tissue develops (cirrhosis), the liver fails. So, an alcoholic with fatty liver who continues to drink may be causing irreversible liver disease. Until recently, it was believed that in non-drinkers a fatty liver was just a curiosity - a consequence of being overweight or a diabetic. New scientific studies have identified non-alcoholic fatty liver as a separate disease entity also with potentially serious consequences. It is now believed that 10-20% of non-drinkers who have a fatty liver will also go on to develop liver cirrhosis. Why this happens is not known. Fatty liver has become the most common cause of cirrhosis in non-drinkers.
NASH (Non-alcoholic steatohepatitis)
In 1980, scientists noted changes on liver biopsies in non-alcoholics that looked very much like the liver damage seen in chronic alcoholics who continue to drink. In addition to excess fat, there were signs of dying liver cells (necrosis), and inflammation. They termed this condition non-alcoholic steatohepatitis, commonly referred to as NASH. (The phrase "steato" simply means fat and "hepatitis" means liver inflammation.) The presence of dying liver cells and inflammation makes NASH a more severe form of fatty liver. Patients with NASH are at risk of progression to cirrhosis.
RISK FACTORS
As mentioned above, the main cause is deposition of excessive fat within the liver. There are many reasons why this might happen including:

• 1. Alcoholism
• 2. Non-Alcoholic Fatty Liver o type II diabetes, non-insulin dependent o obesity - more than 10% over ideal weight o high blood fats, especially high triglyceride levels o certain drugs like prednisone, estrogen, amiodarone, tamoxifen o intestinal bypass for obesity o extensive surgical removal of small intestine o total parenteral nutrition (TPN)
• 3. So far, there is no evidence that heredity plays a role in acquiring the disease. SYMPTOMS: Most patients with fatty liver are asymptomatic. If the liver becomes enlarged, one may experience vague RUQ abdominal pain or nausea.

DIAGNOSIS
Typically a patient who has routine blood tests performed for another reason and is discovered to have abnormally elevated liver enzymes. Perhaps they tried to donate blood and were rejected. It may have been an insurance physical or just a routine checkup. The most common abnormality in the blood tests is two to three-fold elevation in liver enzymes called AST and ALT. In non-alcoholic fatty liver other liver tests are usually normal. In any case, these individuals are usually referred to a specialist to investigate the underlying cause. If there is a history of chronic alcohol abuse, the underlying cause is usually obvious. In non-drinkers, investigation usually focuses on searching for other potential causes of “hepatitis” (inflammation of the liver): viral infection, hemochromatosis (iron overload), Wilson’s disease (copper overload), alpha-one antitrypsin deficiency, gallstones, cancer, or fatty liver. Non-alcoholic fatty liver is suspected in any adult who has unexplained elevated liver blood tests and drinks no more than 2 alcoholic drinks daily. To investigate further, more blood tests are usually required. Imaging studies such as a sonogram or CT scan are helpful in ruling out cancer and gallstones. They can also help determine if the liver contains excessive fat. If NASH is suspected or the diagnosis unclear, a needle liver biopsy is often performed. This is the only way to differentiate simple benign fatty liver from NASH.

TREATMENT
At present, there is no proven therapy to reverse a fatty liver directly. Therefore, treatment is usually directed at the underlying cause. Alcohol must be stopped completely. Potentially offending medications may need to be changed, if possible. Uncontrolled diabetes must be better controlled. High serum cholesterol and triglycerides need to be reduced. Excessive weight must be lost through a diet and exercise program. Several reports suggest that the use of ursodeoxycholic acid (URSO), a natural bile salt, may be helpful.

GallStones

If you have recently been told you have gallstones, you certainly are not alone. Over 25 million Americans now have gallstones and about 1 million new cases are added each year.

What Is The Gallbladder?

The gallbladder is a small pear-shaped hollow sac nestled beneath the liver in the right upper abdomen. It stores about a quarter cup of a yellowish-green material called bile. Made in the liver, bile tastes bitter, and this is why the word bile has come to denote bitterness. A duct is a hollow tube that carries fluid from one place to another, like a water pipe in your home. The gallbladder is really just a side branch of the common bile duct (3), the main duct that drains bile from the liver into the small intestine. The side branch that connects the gallbladder to this main duct is called the cystic duct (2). These ducts carry the bile to the intestine. The pancreas usually shares a common drain with the liver via its pancreatic duct.

When bile enters the small intestine, it breaks up large globs of fat into

smaller globs, a first step in digestion. A healthy gallbladder keeps bile flowing continuously. However, when the gallbladder becomes diseased, the flow slows and bile becomes thick and form sludge. The stagnant bile gradually crystallizes and the crystals clump together to form stones (1).

Symptoms of Gallstones
About half of those with gallstones have no symptoms and need no treatment. Most of them don't even know that the stones are there. Painless stones probably float freely in the gallbladder. But, others are plagued with unpleasant attacks of abdominal pain. The pain occurs when a stone is small enough to escape from the gallbladder and then become lodged in the bile ducts below. The type and severity of symptoms depend upon where the stones lodge.

Called "biliary colic," gallbladder pain is felt as a sharp, severe, stabbing pain, often located in the right upper abdomen. Attacks may last 15 minutes to several hours and may be separated by weeks, months, or even years. The pain often occurs after meals, particularly a high fat meal. Pain may also be felt between the shoulder blades or right shoulder and sometimes in the chest, where it is often confused with a heart attack. There may be associated symptoms of nausea, vomiting, and low grade fever. Untreated, symptomatic gallstones may damage the pancreas and liver, leading to gallstone pancreatitis and obstructive liver jaundice. Patients with symptoms must see their doctor.

RISK FACTORS
While all ages and both sexes are susceptible, women are particularly vulnerable accounting for more than 75% of all patients. Pregnancy, birth control pills, obesity, and a high fat diet are all contributing factors. Obesity increases the risk 6-fold, but individuals on crash diets who lose weight too quickly are also at high risk. Gallstones affect all races, but are more prevalent in some populations. Overall about 10% of Americans have gallstones as compared to Sweden where 44% of the population is affected. In this country, the Native American Indians have the highest incidence of gallbladder disease. Amazingly, over 80% of the Pima Indians of southern Arizona develop gallstones by age 35.

DIAGNOSIS
Gallstones may occasionally be found on x-rays done for other reasons as about 10% are calcified and show up on routine plain x-rays. More than likely, your doctor ordered additional tests based on your symptoms. Possible gallbladder tests include liver and pancreas blood tests that measure "enzymes" in the blood. High levels may signify damage to these organs. Most patients undergo a simple ultrasound exam of the abdomen which uses harmless high-frequency sound waves to create a picture of the gallbladder and ducts. The liver and pancreas can often be seen as well. Special cases may require a more sophisticated x-ray called ERCP. This is a procedure performed by a Gastroenterologist using a lighted "scope" that projects a video image. It can help locate stones or other blockages in the bile ducts.
TREATMENT
In those patients with gallstones who have no symptoms or very mild and infrequent attacks, watchful waiting may be justified. However, for those individuals with persistent or severe symptoms, surgery to remove the gallbladder and gallstones is recommended. Taking out the stones and leaving the gallbladder behind merely invites new stone formation. For effective treatment, both must be removed. There are usually minimal to no consequences to having your gallbladder removed. About 2% of patients will develop loose stools after gallbladder removal which can be treated with diet or medication.

SURGERY
Until 1991, gallbladder surgery was a major undertaking and was often deferred until the last possible moment. Termed open cholecystectomy, this procedure typically required a painful 6 inch abdominal incision, 5 days of hospitalization, and about 4 to 6 weeks of recovery time. In less than a decade, a new technique called laparoscopic cholecystectomy has revolutionized gallbladder surgery. First performed in France in 1987, this simple minimally invasive technique is now possible in over 95% of patients. Instead of a large skin incision, a "lap chole" is performed by making three or four 1/2 inch incisions in the abdominal wall and inserting a tiny video camera to guide the operation. With special instruments, the gallbladder is separated from its attachments and removed through a small incision in the bellybutton. The patient may eat and drink within a few hours after surgery and go home the same day with only a few small Band-Aids on their abdomen. There is very little pain or disfigurement. Most are able to resume full activity within a week's time. Serious complications are rare. Usually that ends the problem. It is possible, but very rare, for gallstones to return once the gallbladder has been removed.

GERD
First of all, heartburn has nothing to do with your heart. Rather, it is a specific form of indigestion caused by a backup, or reflux, of stomach acid into your esophagus. It is usually felt as a burning discomfort in the pit of the stomach or higher up in the middle of the chest beneath the breastbone. Rarely, a referred pain is felt between the shoulder blades, or in the jaw or teeth. Because the searing pain feels concentrated around the base of the breastbone, people often mistake if for a pain in the heart.

Typically, heartburn occurs after meals. Common foods such as fried or fatty foods, tomato products, citrus fruits and juices, chocolate, or caffeine-containing products can produce these symptoms. In severe cases, almost any food seems to cause symptoms. Usually the burning-type chest pain lasts for many minutes and is often made worse after lying flat or bending over. Often there is a sensation of food coming back into the mouth, accompanied by a bitter or acid taste. Sometimes a gnawing sensation awakens an individual from sleep. Relief is usually obtained by standing upright or by taking a dose of antacid.

Heartburn is Common
Almost everyone experiences heartburn occasionally. Over 30 percent of all Americans suffer from heartburn at least once a month and approximately 10 percent suffer daily. Although heartburn is a common malady in our society, it is rarely life-threatening. It can, however, limit an individual's daily activity and sense of well being. For some people, heartburn is so severe that it becomes incapacitating.

CAUSES
Chronic heartburn is a symptom of a disorder called gastroesophageal reflux disease, also called GERD. The cause of this disorder is multifactorial. An important factor involves malfunction of a small one-way valve called the lower esophageal sphincter, or LES.

Every time you eat, your stomach produces hydrochloric acid to help digest your food. To prevent you from digesting your own stomach, your stomach has a special mucous lining to protect itself from the effects of the acid. Unfortunately, your esophagus, or "food pipe," has no special protection against acid - instead you have a one-way valve, the LES. Located at the point where the esophagus joins the stomach, the LES valve acts like a tiny "trapdoor." Normally, the door is closed. When you swallow, this tiny door opens to allow the passage of food into the stomach, but then quickly closes once again to prevent backward flow.

When functioning properly, the LES valve allows food and water to pass into the stomach, but prevents backward flow of the stomach acid. If the LES valve is weak, reflux of stomach contents into the esophagus occurs. Even a little acid from the stomach can irritate the delicate lining of the esophagus causing the severe inflammation and painful symptoms. Often this malfunction of the LES is associated with a hiatal hernia - a common partial displacement of the stomach through the diaphragm and up into the chest cavity.

SEVERE FORM OF HEARTBURN -GERD
When acid regurgitation causes occasional simple heartburn, that is not a problem. But, when the acid exposure is severe, the lining of the lower esophagus becomes inflamed and may cause ulcers to form. GERD refers to this severe damage, not just simple heartburn. Strangely, the rate of GERD is rising dramatically in the United States and Britain. The number of newly diagnosed cases has increased more than five-fold over the past 20 years. The reasons for this increase are unclear.

COMPLICATIONS OF GERD
Heartburn can be a serious problem for some people with GERD. If the delicate lining of the esophagus is exposed to stomach acid for prolonged periods of time, the lining of the esophagus can become inflamed (esophagitis), making it so sensitive that sometimes swallowing is painful. Prompt treatment of esophagitis is necessary to prevent sores (ulcers) from forming in the lining of the esophagus. Left untreated, esophageal ulcers can cause bleeding leading to vomiting of fresh red blood or old "coffee-ground" blood. Sometimes the bleeding goes unnoticed until the passage of black bowel movements.

Continuous inflammation over a long period of time may cause scar tissue to build up in the esophagus, narrowing the opening (stricture) and making it difficult to swallow solid food. This is may require special dilatation to allow normal swallowing function.

When heartburn goes untreated over a long period of time, acid reflux from the stomach can cause cells lining the esophagus to change. The changed lining, called Barrett's Esophagus, is a precursor condition to cancer of the esophagus. The risk of cancer of the esophagus is increased in people who have Barrett's changes. Patients diagnosed with Barrett’s Esophagus need periodic endoscopy with biopsy of the esophagus to survey for development of cancer.

When to see your doctor about heartburn
Not everybody who experience heartburn needs to see their doctor. But if the symptoms are frequent, severe, or progressive, seek medical attention. If you have heartburn, ask yourself these questions:

• Do you take antacids two or more times a week?
• Do you take heartburn medicine(s) other than antacids?
• Does your heartburn interfere with your daily activities?
• Do these symptoms often occur after meals?
• Do these symptoms interfere with your sleep?
• Do you find that your medicine only relieves your symptoms for short periods of time?

TREATMENT
Once your doctor has determined that your symptoms are caused by acid reflux, treatment can be prescribed. This may be as simple as making some life-style changes such as the way you eat. In less severe cases, such simple measures and occasional antacids are sufficient. In more severe cases of GERD, medications such as Tagamet (also available as the generic cimetidine), Zantac, Pepcid, or Axid may be recommended. These are all available either in stronger prescription strength or lower dose over-the-counter form. When medication is prescribed, it is usually for life since the symptoms often return if the medication is discontinued.

More powerful prescription medications such as Nexium, Protonix, Aciphex or Prevacid are often used in patients with persistent symptoms. These medications, particularly are very effective in even the most difficult cases. Short term they are very safe. The main known side effect is cost since treatment is usually lifelong. Long-term side effects are unknown.

With such effective medications, surgery is rarely necessary. However recent techniques have raised interest in surgical treatment. In the past surgery for GERD often meant a major surgical incision and up to a 6 week recovery period. A newer laproscopic technique using a scope and three or four tiny incisions is now available. This new procedure, called a Nissen Repair, allows a shorter hospital stay and recovery period and may make surgery a better option for selected patients.

Ten ways to relieve heartburn

Here are a few simple life-style changes you can follow to relieve some of the symptoms associated with acid reflux and heartburn:

• Avoid tobacco. It increases acid production. If you can't stop completely, cut down.
• Avoid excessive use consumption of caffeine, alcohol, chocolate, peppermint, and fatty foods. Of course, also avoid any food you know that will cause you to have episodes of heartburn.
• Avoid bending or stooping after eating - this forces acid into your esophagus and causes heartburn.
• Eat smaller, more frequent meals during the day. Try to avoid eating within 3 hours of bedtime.
• Let out your belt a notch or two and wear looser, more comfortable clothing. Avoid girdles and other tight garments. The extra pressure on your abdomen forces acid upward.
• Lose weight if your doctor feels this would help. Exercise is good, but avoid sit-ups and leg lifts which can worsen acid reflux.
• Put gravity on your side. Sleep with the head of your bed raised. Don't use two pillows but raise the headboard about 6"-8" on blocks.
• Use over the counter antacids if needed. Tums and Gaviscon are often helpful. But if you need these medications more than three times a week, see your doctor. Take prescription medication according to your doctor's instructions.
• Take all medications exactly as prescribed by your doctor.

Contact your doctor if symptoms continue despite these simple measures.

Helicobacter Pylori

Helicobacter pylori (he-lick-oh-back-ter pie-lorrie) is an unusual name that refers to a tiny acid-resistant germ (bacteria) that has been found to be a major cause of peptic ulcer disease. Also known as H. pylori, this organism was first reported in the stomach of patients with ulcers in 1982 by Dr. Barry Marshall of Perth, Western Australia, but its significance was not recognized until the past several years. Actually, it is quite surprising that this germ can even survive inside your stomach because all other germs are immediately killed by the powerful stomach acid. The infection remains localized to the stomach lining and does not spread throughout the body. If the infection is not treated, it usually lasts a lifetime.

Once Helicobacter pylori invades your stomach lining, it produces an ammonia-like chemical which neutralizes acid in the immediate vicinity, thus protecting itself from stomach acid. The bacteria do not actually invade the stomach cells as certain other bacteria can. The presence of H. pylori is recognized by the host’s immune system and white blood cells move into the area, and the body even produces Helicobacter antibodies in the blood.


ASSOCIATION WITH ULCERS


Until the discovery of this bacteria, it was felt that most ulcers were caused by lifestyle factors such as poor diet, too much stress, heavy drinking, and smoking. It now seems in the majority of cases the real culprit may be this tiny bacteria. As Helicobacter invades the stomach lining, it disrupts the protective mucous layer and allows the corrosive stomach acids to come in direct contact with the delicate tissues below. This can then lead to peptic ulcers and stomach inflammation called gastritis. In fact, chronic gastritis is the hallmark of Helicobacter. It is found in nearly all those infected.

The real breakthrough is the evidence that Helicobacter infection is the culprit in up to 90% of duodenal ulcers. Most of the other 10% are probably caused by too much aspirin, ibuprofen, and other anti-inflammatory drugs. Stress and diet may play a role in aggravating an ulcer, but no longer seem to be the main cause. The good news is that we now have medications to eradicate Helicobacter which speeds ulcer healing, and more importantly, greatly reduces the risk of ulcer recurrence. Soon, for many people, ulcers will be a thing of the past.


ASSOCIATION WITH CANCER
There is also some evidence that two types of cancer may be increased in patients who harbor this infection - stomach cancer and lymphoma. This does not mean that every person who has Helicobacter will develop cancer; in fact, very few do in this country. However, left untreated for decades, Helicobacter may be an important risk factor and therefore is another reason why it should be treated.


RISK FACTORS FOR HELICOBACTER INFECTION
If you have Helicobacter, you are not alone. It is quite common and may be the most common infection in the world. By age 20, over one-fourth of Americans are infected. The rate of infection increases with age, so it occurs even more often in older people. But, no one has satisfactorily explained how anyone picks up this germ in the first place, though it probably reaches the stomach by way of the mouth through contaminated food, fluids, or utensils. It is not transmitted in the blood and as far as we know. Helicobacter is not transmitted through the water supply in the United States. The infection can occur in anyone, but seems more prevalent in countries where sanitation is poor. The common housefly has recently been felt to play some role. Helicobacter is quite common in our society and often affects more than one member of a household. In many cases, it does not produce symptoms. In other words, the infection can occur without the person even being aware of it.
At the present time research is being done on prevention through vaccination. Hopefully, this will be available in the future. This would probably have to be administered as part of the routine childhood immunizations to be most effective.
DIAGNOSIS
Symptoms, when they occur, may vary widely, but the most common ones are abdominal pain, nausea, indigestion, gas and bloating. This infection is most accurately diagnosed by a direct biopsy and laboratory analysis of samples taken from your stomach lining. This can be simply and painlessly done with a endoscopy (EGD) procedure. Endoscopy has the advantage of accuracy and allows a direct inspection and biopsy of the stomach and duodenal lining to best assess if ulcers or cancer are present.

Two other tests are available. A breath test involves swallowing a substance called urea. If the bacteria is present, the urea is broken down into carbon dioxide which is then exhaled and can be measured in the breath. A positive breath test means there is an actual active infection in the stomach with H. pylori.

Also, there is a blood test that measures antibodies against Helicobacter. But, a positive antibody test can mean either an active infection, or that it was present in the past and now is cleared.

WHO TO TEST
Only your doctor can diagnose Helicobacter and recommend a treatment plan. If you have symptoms of an ulcer such as a sharp gnawing abdominal pain 1 to 3 hours after eating, you should be tested. If you have ulcers or a past history of ulcers, you should be tested. Those with a first degree relative (a parent or sibling) who had stomach cancer should also be tested.

WHO TO TREAT

The real breakthrough is that now many ulcers can be cured. If you have a duodenal or gastric ulcer and have this infection, the chances of the ulcer returning in the future is great. However, many scientific studies have proven that eradication of Helicobacter markedly reduces the risk of ulcer recurrence. For the first time, ulcers can now be cured in most individuals.

Since this infection is so common, some doctors feel that it need not be treated if there are no symptoms. More research is needed, but most doctors now recommend treatment regardless of symptoms because of the increased risk of cancer in the untreated individual.
TREATMENT
Treatment can be a nuisance since there currently is no single antibiotic that satisfactorily kills Helicobacter. For now we must use a combination of multiple drugs. These include multiple antibiotics as well as medications to reduce stomach acid. Unfortunately, this multi-drug treatment can cause unpleasant side effects, but can clear the infection in most cases. Hopefully, a simpler more effective treatment will be available in the future. Your doctor can best decide which treatment regimen is appropriate for you.

In most cases, post treatment testing is not advised. If the organisms are not resistant to therapy, the infection can be cured in up to 90% of cases. If symptoms do return, your doctor can perform additional tests if needed after the treatment is completed to see if the infection has been successfully eradicated. Both a stomach biopsy during a repeat endoscopy procedure and the breath test can determine if the infection is gone. A breath test at least four weeks after therapy is finished is the simplest non-invasive way to assess cure. The blood test is not useful to assess cure since it may still show antibodies to Helicobacter for over a year after the infection is cleared. If the blood test turns negative, however, it indicates cure.

The risk of recurrent Helicobacter infection is believed to be less than 1% per year.

Hepatitis C

Hepatitis C is an infection of the liver caused by the hepatitis C virus (HCV). Hepatitis C is one of five (A, B, C, D, and E) viruses that are able to infect the liver. A virus is a very small organism, invisible to all but the strongest microscopes. Unlike other living organisms, a virus cannot reproduce itself. It needs to take over the reproductive mechanism of other cells within the body, like liver cells. Once a virus has invaded a cell, it reproduces quickly, eventually bursting the cell and scattering new virus particles into the bloodstream. These new viruses can then search out and invade more liver cells, repeating the process over and over. Hepatitis C viral particles are circulated throughout the body via the blood, but primarily do their damage within the liver.

Fortunately, your body's immune system has a very efficient type of "radar tracking" mechanism which allows identification and destruction of virus particles - before they can spread. Every time you get a virus, like a cold or flu, there is a fierce battle being waged between the rapid formation of new virus particles and your immune system's ability to destroy them. Your immune system is pretty smart. It usually wins the battle and the infection is cured. In most cases, however, hepatitis C is a stealth infection that eludes the body’s immune defense. It does this by constantly changing its appearance and the immune response cannot keep up with it. The infection is not cleared and becomes chronic, or permanent, in three cases out of four. Most people with this chronic infection are completely asymptomatic. Over time, however, as the immune response repeatedly attempts to destroy the virus in the liver, inflammation of the liver occurs. This liver inflammation is called hepatitis. Once is has become chronic, the condition is called chronic hepatitis C. A byproduct of this inflammation in some cases is elevation of the liver enzymes (AST & ALT) detectable on blood tests.

Chronic hepatitis C has become a serious public health problem in the United States. If your doctor has told you that you have this illness, you are not alone. The U.S. Center for Disease Control (CDC) estimates that at least 4.5 million Americans are now infected with this virus and over 170,000 new cases are added each year. More than 4 times as many people are infected with

Hepatitis C than HIV-AIDS. There are approximately 170 million hepatitis cases worldwide where it is the most prevalent of all the forms of hepatitis.

HCV first surfaced in the 1970's as a mysterious post-transfusion virus dubbed "non-A non-B hepatitis" since research did determine that it was neither the virus that causes hepatitis A nor hepatitis B. The virus was finally isolated and named "hepatitis C" in 1989. Since then scientists have been scrambling to find out how many people have it, how it is transmitted, and how to treat it. An antibody test to screen and protect the blood supply was developed in 1990.

SYMPTOMS OF HEPATITIS C
Hepatitis C is usually transmitted asymptomatically. Acute infection with this virus rarely causes any symptoms at all. In a small percentage of cases, nonspecific flu type symptoms may be present. Most will not have any symptoms at all, and therefore not know anything is wrong until it is suspected after discovering abnormal liver tests during a physical exam. It can be present for decades before symptoms such as loss of appetite, fatigue, nausea, vague stomach pain, and jaundice (a yellowing of the skin and whites of the eyes) occur.

LIVER DAMAGE
HCV is a potential time bomb with a fuse of unknown length. Many infected persons remain healthy indefinitely; but, as mentioned above, 75% will develop a chronic infection that they are unable to clear. This can lead to cirrhosis (scarring) of the liver and 20% of infected patients develop life-threatening liver failure 15 to 20 years after their initial infection. At 30 years the risk of liver cancer increases.

RISK FACTORS
A blood-borne virus is spread primarily by exposure to human blood. HCV is most often transmitted by blood transfusions and IV drug user's contaminated needles, but the source of many infections is unknown.
You are at risk for HCV if you:

* ever injected drugs or shared needles
* ever shared an apparatus to snort cocaine
* have a job that exposes you to human blood
* are a hemodialysis patient
* received a blood transfusion before 1990


You may be at risk if you:

* have had unprotected sex with multiple partners
* live with a person who has hepatitis C
* have had a tattoo or body piercing
HCV is not spread by food or water and there is no evidence that HCV is spread by sneezing, coughing, hugging, or other casual contact.

PREVENT TRANSMISSION
People who have HCV should remain aware that their blood, and possibly other body fluids, are potentially contagious for the rest of their life. Care should be taken to avoid blood exposure to others by sharing toothbrushes, razors, needles, etc. In addition, infected individuals can never donate blood and should inform their medical and dental care providers so that proper precautions can be followed.

HCV has been transmitted between sex partners and among household members; however, the degree of this risk is unknown. Studies of HCV and sexual transmission offer conflicting results. A 1991 study from Stanford University showed no evidence of HCV in the urine, semen, or vaginal secretions of infected individuals with HCV. But similar studies have shown evidence of HCV in 5-27% of sexual partners.

Researchers seem to agree that if it is transmitted sexually, it isn't very efficient. The risks of catching HCV from an infected partner are estimated at less than 1% per year of exposure. Each couple will have to decide what is best for them, but currently the CDC does not advise changing sexual habits or using condoms in long-term monogamous relationships. As always, all people with multiple sexual partners should use condoms to reduce the risk of acquiring or transmitting HCV as well as other sexually transmitted diseases.

VACCINE
While there are vaccines for other forms of hepatitis such as hepatitis A and hepatitis B, there currently is no effective vaccine for hepatitis C. Much research is being done; however, since billions of healthcare dollars are being spent treating hepatitis C related liver disease complications worldwide. HCV patients should be vaccinated against hepatitis A and B. Infection with either could speed the liver damage done by hepatitis C.

DIAGNOSIS
Usually by accident. Since most cases have no symptoms, HCV is usually discovered during a routine liver blood test taken before donating blood, an insurance physical, or just a checkup in your doctor's office. Once your doctor notes an elevation in your liver enzymes he/she will usually request additional blood tests to confirm the abnormality and to determine the cause. A hepatitis profile if often requested which test for hepatitis A, B, and C. If the test is positive for hepatitis C then additional blood tests are done to confirm active infection, the amount of virus present and type of hepatitis C (genotype). Since the extent of liver damage cannot be accurately determined by blood tests, often a needle biopsy of the liver is recommended.

TREATMENT
Alcohol use in any form must be stopped. Studies are clear the Hepatitis C patients who regularly ingest alcohol have more active hepatitis and are much more likely to rapidly progress to liver failure. In addition drug treatment of HCV does not seem to work in alcohol users.
Being overweight also appears to increase the amount of damage the virus does to the liver. Apparently fat deposited in the liver increases scarring caused by inflammation from the virus. Progressive scar tissue formation then leads to cirrhosis. A weight loss program, if necessary, and staying within 10 % of your ideal body weight is suggested

Currently the most effective drug therapy involves the use of two medications "Pegylated Interferon and Ribavirin" given in combination for a 24 - 48 week period. The duration of therapy and projected treatment response is variable and depends on multiple factors including the genotype of the hepatitis C infection.
Side effects of these medications are common and may preclude treatment in some patients. Interferon often makes patients feel as if they had a lingering case of the flu with fever, chills, headache, tiredness, loss of appetite, joint pain and muscle aches. These side effects may get better as the body gets used to the extra interferon. Tylenol or Advil plus rest are helpful.
Treatment requires frequent follow-up visits and blood tests to monitor the effectiveness of treatment and potential toxicity. Interferon is associated with bone marrow suppression that causes lowered levels of white blood cells (leukopenia) and platelets (thrombocytopenia). Occasionally the dose of the Interferon needs to be lowered to avoid risk of infections caused by leukopenia. Lowering the dose of Interferon usually results in improvement in the white blood cell count, but could reduce its effectiveness against the Hepatitis C virus. Alternatively, leukopenia can be treated with another injectable drug called Neupogen, which stimulates the bone marrow to produce more white blood cells. This strategy usually allows the patient to continue to receive the full prescribed dose of interferon.

Ribavirin causes everyone to be anemic, which is a reduction in red blood cell mass. A side effect of anemia is fatigue. Some patients require a dose reduction or discontinuation of ribavirin if the anemia becomes too severe. An alternative strategy to treat the anemia commonly employed is to prescribe Procrit, another injectable drug which stimulates the bone marrow to produce more red blood cells. Cardiac patients and some women of child bearing age may not be candidates for this drug and your doctor will help you decide if Ribavirin use is right for you.
Depression can occur or be aggravated by the use of interferon. Be sure to tell your doctor if you have suffered from depression in the past or develop symptoms while on therapy.
Note: Patients with liver disease and/or who regularly use alcohol should never take more than 4 regular-strength Tylenol per day and should not take Tylenol on a daily basis due to risk of liver failure.

GENOTYPE
Prior to initiating treatment a blood test will be needed to determine your genotype. Genotype is the genetic make-up of the virus. The virus can mutate or change its genetic makeup. By varying its structure, it has evolved into six known genotypes. Determining the genotype helps the doctor determine the duration of therapy and projected response. Genotypes 1a and 1b are the most common in the U.S., accounting for more than 75 percent of all infections. For these genotypes, the hardest to treat, the recommended length of treatment is 48 weeks. For those with genotype 1, the Sustained Virologic Response, (SVR), for combination therapy with Pegylated Interferon + Ribavirin is 40 – 50%. Genotype 2 and 3 are present in approximately 20 percent of patients. These genotypes are easier to treat and respond to a recommended treatment period of 24 weeks, with an anticipated SVR of 80% with combined Pegylated Interferon + Ribavirin.

LIVER TRANSPLANTATION
In severe cases if the liver is damaged beyond repair even with viral eradication, liver transplant is an option. In fact, Hepatitis C has now become the most common reason to perform liver transplant in the United States.

Hiatus Hernia

The hiatus hernia is one of the most misunderstood and maligned conditions in medicine. People blame this hernia for much more than it ever does. Patients with a hiatus hernia need to understand what it is and what might occur with it. Most importantly, they need to know it is unusual for serious problems to develop from this type of hernia.
Anatomy
The diaphragm is a sheet of muscle that separates the lungs from the abdomen. When a person takes a deep breath, the dome-shaped diaphragm contracts and flattens. In doing this, the diaphragm pulls air into the lungs. The left diaphragm contains a small hole through which passes the tube-shaped esophagus that carries food and liquid to the stomach. Normally this hole, called a hiatus, is small and fits snugly around the esophagus. The J-shaped stomach sits below the diaphragm.
What Causes a Hiatus Hernia?
In some people, the hiatus or hole in the diaphragm weakens and enlarges. It is not known
why this occurs. It may be due to heredity, while in others it may be caused by obesity, exercises such as weightlifting, or straining at stool. Whatever the cause, a portion of the stomach herniates, or moves up, into the chest cavity through this enlarged hole. A hiatus hernia is now present. Hiatus hernias are very common, occurring in up to 60 percent of people by age 60.
What Are the Different Types of Hiatus Hernia?
1. Sliding Hiatus Hernia—In this most common type of hiatus hernia, the herniated portion of the stomach slides back and forth, into and out of the chest. These hernias are usually small and usually cause no problem or even symptoms.
2. Fixed Hiatus Hernia—In this case, the upper part of the stomach is fixed up in the chest. Even with this hernia, there may be few symptoms. However, the potential for problems in the esophagus is now increased.
3. Complicated or Serious Hiatus Hernia— Fortunately, this type of hernia is uncommon. It includes a variety of patterns of herniation of the stomach, including cases in which the entire stomach moves up in the chest. There is a high likelihood that medical problems will occur with this hernia and that treatment, frequently involving surgery, will be required. Complicated hernias are unusual and uncommon.
Symptoms
In the majority of patients, hiatus hernias cause no symptoms. This is especially true of sliding hernias. When symptoms occur, they may only be heartburn and regurgitation, when stomach acid reflexes back into the esophagus. Some patients with fixed hiatus hernias experience chronic reflex of acid into the esophagus, which may cause injury and bleeding. Anemia, or low red blood cell count, can result. Further, chronic inflammation of the lower esophagus may produce scarring and narrowing in this area. This, in turn makes swallowing difficult, and food does not pat easily into the stomach.
Does a Hiatus Hernia Cause Pain and Indigestion?
It is wrong to always blame a hiatus hernia for pain and indigestion. Hiatus hernias generally do not cause acute pain. This symptom may result from other disorders, such as peptic ulcers or ever heart disease. Some patients with coronary heart disease fool themselves into believing their discomfort is due to a hiatus hernia. If upper abdominal pain or indigestion occurs, a person should not mislead himself into thinking the cause is a hiatus hernia. Instead, the patient should first seek medical advice.
Diagnosis
Diagnosis of a hiatus hernia is typically made through an upper GI barium x-ray. A complementary test is gastroscopy, or upper-intestinal endoscopy, in which the physician visually examines the esophagus and stomach using a flexible scope while the patient is lightly sedated.
What Are the Complications?
The complications of hiatus hernia are:
1. Chronic heartburn and inflammation of the lower esophagus, called reflux esophagitis.
2. Anemia due to chronic bleeding from the lower esophagus.
3. Scarring and narrowing of the lower esophagus causing difficulty in swallowing.
4. While sleeping, stomach secretions can seep up the esophagus and into the lungs causing chronic cough, wheezing, and even pneumonia.
In addition, the complicated hernia can cause serious problems such as difficulty in breathing or severe chest pain.
Treatment
Treatment is called for only when the hernia results in symptoms, such as persistent heartburn or difficulty in swallowing. Acid inflammation and ulceration of the lower esophagus also require treatment. General guidelines for treating heartburn and esophagitis (inflammation of the esophagus) are:
—Avoid (or use only in moderation) foods and substances that increase reflux of acid into the esophagus, such as: nicotine, caffeine, cigarettes, chocolate, fatty foods, peppermint, alcohol, spearmint.
—Eat smaller more frequent meals and do not eat before bedtime.
—Avoid bending, stooping, abdominal exercises, tight belts and girdles, all of which increase abdominal pressure and cause reflex.
—If overweight, lose weight. Obesity also increases abdominal pressure.
—Prescription medications. Certain drugs, such as intestinal anti-spasmotics, calcium channel blockers, and some antidepressants weaken the muscle strength of the lower esophagus. Elevate the head of the bed 8 to 10 inches by putting pillows or a wedge under the upper part of the mattress. Gravity then helps keep stomach acid out of the esophagus while sleeping.
Other Treatments
Drugs—Some medicines effectively reduce the secretion of stomach acid, while others increase the muscle strength of the lower esophagus, thereby reducing acid reflux. Surgery—The complicated hiatus hernia requires surgery occasionally on an emergency basis. Surgery otherwise is reserved for those patients with complications that cannot be handled with medications. The mere presence of a hiatus hernia is not a reason for surgery.

Gas
The complaint of "too much gas" is one of the leading problems brought to doctors who specialize in bowel diseases. Many individuals see the doctor believing that their digestive tract is malfunctioning because of excessive gas. They may fear that some serious ailment is present. Fortunately, this is seldom the case. Gas in itself is not dangerous; its main consequence is usually embarrassment and social isolation for the person who can't “control it”. Usually at the most inopportune moment, our body pulls a fast one, emitting offensive sounds or odors.

Besides being a social drawback, excess gas can be downright painful for some people. The abdomen can become painfully distended, especially right after eating. Bloating of the abdomen can be so severe that clothing doesn't fit. Such problems also lead some suffers to believe that there is something seriously wrong with their digestive tracts. Again, this is seldom the case.

GAS IS NORMAL
Though the subject of gas is not one that most of us talk about, the truth is that all of us have gas in our intestinal tract and must get rid of it in some way. Most gas is odorless. Though proportions vary from person to person, gas is largely composed of hydrogen, nitrogen, and carbon dioxide, with a touch of oxygen. In addition, a third of the adult population produces copious quantities of methane, while the rest emits little or none. Some intestinal gas smells. Intestinal bacteria produce several sulfur-containing compounds that are primarily responsible for this odor. Unfortunately, the human nose can detect hydrogen sulfide in concentrations as low as one-half part per billion.

The passage of gas through the rectum and belching are normal and necessary functions that allow the body to rid itself of gas. It happens to all of us. Belching, or burping, is the passage of gas from the stomach. We all know the common term for passing gas through the rectum, but the correct medical term is flatulence, or passing flatus.

This problem is certainly not new. Strong winds from down under fuel some of the oldest and funniest jokes in the world - until they affect us, that is. In ancient times, Hippocrates investigated flatulence extensively, and physicians who specialized in it became known as "pneumatists." Anyone familiar with Chaucer will appreciate the fact that "breaking wind" has been the subject of humor and misery at least since the early days of the English language. And in early American history, such great men as Ben Franklin taxed their minds seeking a cure for "escaped wind."

How Much Gas Is Normal?
It varies from person to person. Studies done on young adults have shown that the average person generates 1 to 3 pints a day. It is of passing interest that the normal individual emits gas from below about 12 to 25 times per day. However, individual ability to tolerate air in the stomach and intestines varies and some people simply produce more gas than others.

WHERE DOES GAS COME FROM?
The two main sources of gas are swallowed air and gases that are produced within the intestine. For practical purposes, gas that is brought upward is swallowed air, whereas that rumbling in the lower region is produced locally.

BELCHING
A belch is the sudden escape of gas from the stomach. In the England of King Henry VIII, a hearty belch after a meal was quite acceptable. Even today it is a gesture of appreciation for a meal in the Middle East. Victorian manners have stripped the belch of any respectability in our society. While belching might be an act of satisfaction in the fishing camp, it is a slip of sheer horror in the dining room. Despite this social stigma, release of gas from the stomach may relieve vague abdominal discomfort and, on occasion, is a necessity. A satisfying belch after meals is normal and eases distension caused from the meal and accumulated air.

Repeated belching, however, likely indicates air swallowing. Swallowing air is called aerophagia. With practice one may suck air into the esophagus which can then be forced upward. This art is often mastered by adolescents who delight in demonstrating their burping prowess to their peers.

We all swallow some air when we eat or simply swallow saliva. Drinking a glass of water can result in two times as much air in the stomach as water. It seems that some individuals repetitively swallow air and then return it with a belch.

Rapid, gulpy eaters trap air with their food. Eating while stressed can do the same thing. Gum chewing, smoking, and poorly fitting dentures can cause excessive production of saliva which must be swallowed. Repeated swallowing also occurs with a postnasal drip or dry mouth. A few people gulp air as a nervous tic - a trait often portrayed by cartoonists whose heroes "gulp" when faced with a crisis. Aerophagia may just be an intractable bad habit or a manifestation of stress. It is not usually a symptom of serious gastric disorder.

FLATULENCE
Gas that escapes from below has no status in any respectable society. In fact, in Ancient Rome, passing gas in public was illegal. But, whether we like it or not, gas is part of the human condition. Gas in the lower bowel never killed anyone-but that's about the best that can be said about it. Millions of people spend too much time worrying about foods they shouldn't eat and noises they shouldn't make.

The foods we eat can be a factor in the production of gas. The carbohydrates (sugars and starches) in some foods are not completely digested in the small intestine. When these undigested sugars reach the colon, they are fermented by the bacteria that normally live in the colon. This fermentation often results in gas - the same way fermenting grapes make champagne.

The most common source of undigested carbohydrate is lactose, or milk sugar, which is found in dairy products such as milk, skim milk, and cottage cheese. About 20% of whites and most non-white people lack the enzyme lactase, which is necessary to break apart and absorb lactose. Intestinal bacteria step in to aid the process and this fermentation causes gas.

Lactase deficiency is especially seen in blacks, Orientals, and those of Mediterranean origin. The results can be dramatic. Just two grams of lactose can release 1400 cc of hydrogen. One lactase-deficient patient, after drinking 2 pints of milk, produced flatus 141 times - a record that has been submitted to the Guiness Book of World Records.

The next most common source of gas is beans. Leave to doctors to study what cowboys have known for years. If a subject is switched from a normal diet to one in which half of the calories are provided by pork and beans, the result is a spectacular tenfold increase in gas production - truly an explosive situation. Though beans have acquired a nasty reputation, it's not the beans themselves that cause flatulence, but the inability to digest them properly. Beans contain a sugar that cannot be digested by the human intestine. Besides beans and dairy products, many other fruits and vegetables are gas producers. However, one creature's flatus is another's fulfillment. Certain colon bacteria are capable of digesting these substances producing hydrogen, methane, and carbon dioxide in the process. Excessive gas is the result.

Helpful Hints to Reduce Excessive Gas

• Try to limit air swallowing. The prevention of air swallowing is important in limiting repetitive belching. A time-honored remedy for repeated burping is to grip a pencil between the teeth. It is impossible to suck air into the esophagus with the teeth parted this way.
• Eat slowly and don't talk while eating. Chew your food thoroughly, instead of gulping it down.
• Avoid using a straw or drinking out of a narrow-mouthed bottle. It promotes air swallowing.
• Avoid carbonated beverages like soft drinks and beer. Carbonated beverages are an obvious source of swallowed gas as gusty belching is a familiar background sound in a barroom.
• Avoid chewing gum, or sucking on candy.
• Have loose dentures refitted. They trap air bubbles and saliva, causing you to swallow more frequently.
• Treat postnasal drip.
• Avoid smoking or chewing tobacco.
• Some people have a nervous habit of swallowing air. Use relaxation techniques, such as deep breathing or yoga, to reduce stress.
• Increase your physical activity. Any aerobic activity like running or even walking will speed up digestion and help eliminate gas, but might make things unpleasant for those bringing up the rear. If abdominal distension is a problem, try sit-ups to firm up the abdominal muscles. Walking after eating moves the air bubble to the upper stomach where it can be easily belched.
• Reduce your lactose load. Lactose is found in dairy products such a milk, skim milk, and cottage cheese. Aged cheeses, such as Swiss or cheddar, have little lactose. Yogurt is usually well tolerated by lactose- intolerant people. If milk bothers you, try Lactaid or DairyEase.
• Avoid sorbitol and fructose. Sodas and hard candies which contain sorbitol and fructose sugars cause extra gas and should be avoided.
• Go slow on high fiber. Fiber is healthy but it will increase your gas, especially if you increase the amount too quickly.
• Presoak dried beans and discard the water. This helps remove the gas-causing starches. You might also try a few drops of Beano before meals. This harmless natural enzyme can help reduce gas formation. It can be purchased without a prescription at your pharmacy.

Over-the-counter remedies
If bacteria in the colon produce the gas, you might ask why not use an antibiotic to kill them. Unfortunately, this approach kills the beneficial bacteria as well as the gas-producers. The results are unpredictable and there may be serious side effects. You might try over-the-counter medications like simethicone. It may help reduce gas by dispersing gas pockets and preventing more from forming. It doesn't help everyone but it has no known side effects. It can be purchased without a prescription under the brand names of Mylicon, Phazyme, and Gas-X, It is also found in the antacids Maalox Plus and Mylanta II.

For those who have found no other solution to excess gas, activated charcoal sold in 250 mg capsules has been shown to relieve discomfort and reduce the volume of gas. Activated charcoal tablets help, too, acting like a magnet in your system, adsorbing many chemicals, like gas. No one knows exactly why activated charcoal works, but it probably inhibits gas-producing bacteria and absorbs hydrogen and carbon dioxide. Since activated charcoal can soak up medicine as well as gas, be sure not to take it within 2 hours of any important prescription medications. This is a safe and inexpensive form of therapy, but one should be aware that charcoal will turn the stools black. Two brands are Charco-Caps and Flatulex.

WHEN TO SEEK MEDICAL ATTENTION
Though gas by itself is not usually a sign of a problem, persistent and troublesome symptoms may mean that something else is wrong. If bloating or abdominal discomfort are severe, or accompanied by other symptoms such as weight loss, rectal bleeding, or change in bowel habits, check with your doctor.

Ischemic Colitis

All organs of the body require oxygen and nutrients which are carried in the blood stream. If the flow of blood is interrupted for more than a few minutes, cells begin to die and damage occurs in that organ. A typical example would be a heart attack. A “heart attack” occurs when a blood clot causes a blockage in an artery supplying blood to the heart. Part of the heart muscle dies and is replaced by scar tissue. Another example familiar to most people would be a stroke, or "brain attack." A stroke occurs when a blood clot causes a blockage in an artery in the brain. Ischemic colitis can be thought of as a “colon attack” since the mechanism of injury is the same.
The word Ischemia means lack of blood. Colitis means inflammation of the colon. In people with ischemic colitis, a portion of the colon becomes inflamed and ulcerated due to a shortage of oxygen-rich blood. Ischemic colitis can be thought of somewhat like having a "stroke" in the colon. If blood flow to the colon is reduced sufficiently, damage occurs to the inner lining, or mucosa. If the damage is severe enough, the mucosa dies and is sloughed off leaving a crater, or ulcer.

ANATOMY OF A “COLON ATTACK”
The heart pumps this blood into the abdominal aorta, the main artery that enters the abdomen. The abdominal aorta has three major branches that carry blood directly to the digestive tract:
Celiac Artery - The celiac artery supplies the stomach and the upper part small intestine, or duodenum.

Superior Mesenteric Artery - The superior mesenteric artery (SMA) supplies blood to the rest of the small intestine and the right and mid-portion of the colon.

Inferior Mesenteric Artery - The inferior mesenteric artery (IMA), the smallest of the three and the one most often affected by "hardening of the arteries," supplies blood to the left side of the colon and the rectum.
As a backup, these three branches intercommunicate through smaller collateral vessels. In about 5% of individuals, collaterals between the SMA and IMA are underdeveloped or absent. This makes the area in-between more vulnerable to drops in blood flow, often referred to as the "watershed area."
Occlusive vs. Non-occlusive causes

In general, about 10% of the blood pumped out of the heart goes to the intestinal tract. But, the exact amount may vary from moment to moment. When ischemic colitis occurs, blood flow to a portion of the intestine is momentarily interrupted. Many factors may be responsible. Obviously, intestinal blood flow can be reduced by a physical blockage in the artery, like a blood clot. This is called occlusive disease and represents a minority of causes.

However, in most cases, ischemic colitis is non-occlusive - meaning that there is no blood clot obstructing the flow of blood. Rather, there may be a temporary spasm of small blood vessels within the colon wall due to changes in heart rate, blood pressure, or various medications. This spasm, termed "vasoconstriction," may reduce blood flow enough to damage that portion of the colon.
PATHOLOGY

Whatever the cause, if blood flow is reduced for a long enough period of time, that portion of the colon will be damaged. The region of colon most commonly affected is the splenic flexure region of the colon. However, the damage is not uniform. The damage mostly occurs on the more delicate inner lining of the colon called the mucosa. The type of damage includes inflammation and ulceration of the colonic mucosa.

RISK FACTORS

Ischemic colitis is very much like coronary artery disease. Both conditions are caused by decreased blood flow - one in the heart, and the other in the colon. So, the risk factors for ischemic colitis are very similar to those of coronary heart disease: age over 50, smoking, high blood pressure and high cholesterol.

There has been some recent evidence that some patients with this problem suffer from an acquired or congenital abnormality in blood clotting called a "hypercoagulable state." Recent studies suggest that this may cause such blood clots and be the underlying cause of some cases of ischemic colitis. Occasionally, an individual will have an episode without any identifiable risk factors, just bad luck.

SYMPTOMS

Classic symptoms include acute onset of severe abdominal pain, usually in the left lower quadrant of the abdomen. This may be followed by cramping, bloody diarrhea, nausea or vomiting.
DIAGNOSIS

Direct visualization of the lining of the colon with a limited colonoscopy is the best and most rapid diagnostic test. Though the appearance of the ischemic colon lining is suggestive of the diagnosis, a biopsy taken at the time of the colonoscopy can confirm the diagnosis. Blood and stool testing along with CT scan can provide additional information.

TREATMENT

In the majority of cases treatment is not necessary, and the damage to the lining of the colon repairs itself spontaneously. Severe cases may require brief hospitalization for diagnostic studies, IV fluids and antibiotics. A small percentage of severe cases, ischemic colitis will progress to gangrene of the bowel and require surgical removal of the colon.

Irritable Bowel Syndrome IBS

Irritable bowel syndrome (IBS) poses something of a dilemma: Physicians readily recognize when a person has it, but describing a consistent pattern of symptoms is nearly impossible. People with an irritable bowel may complain of cramping pain in any part of the abdomen, feeling bloated, "gas," constipation as well as diarrhea, and excessive mucus in the stool - singly or in any combination! Often, the same person may complain of either constipation or diarrhea, later experience the other symptom, and then alternate again. The symptom that occurs most frequently also will vary from individual to individual.
Worldwide, IBS affects about 1 in 7 to 1 in 10 people. Over 22 million Americans suffer from this condition, which is second only to the common cold as a cause of absenteeism from work. Reports indicate that three times as many women as men are afflicted with irritable bowel syndrome. Researchers speculate that the fluctuation of reproductive hormones during menstrual cycles may increase the occurrence of these symptoms. The truth is that the cause or causes of IBS are not well understood at all. It is very likely that multiple factors are involved.
You can guess at the number of disorders that researchers thought produced IBS by ticking off the names given to this problem over the years. Irritable bowel syndrome has been called psychogenic colitis, mucous colitis, or just plain colitis - suggesting that there is inflammation (or "-itis") of the lining of the colon. This is a misnomer because no inflammation is present.
Perhaps, as some have suggested, if there is an inflammation it is due to a bowel infection. Nowadays, most physicians do not believe infection is a factor. They do think, though, that some irritation of the small or large intestine is involved.
Irritable bowel syndrome has also been called psychogenic colitis, or the nervous gut, in the belief that psychologic distress - "nerves," depression, or anxiety - causes the onset of symptoms.
At one time, intolerance to certain foods and food allergies were considered major factors in IBS. While we do not know that this is not the case, it is unlikely to be the only cause.
Another name for IBS was spastic colitis or spastic colon. This referred to the painful contractions a sufferer would feel inside his or her lower gut. These abnormal, uncoordinated contractions, or dysmotility, may be linked to a change in the "firing" of electrical signals that control muscular activity. This "pacemaker" mechanism is similar to the system controlling the contraction of heart muscle. And as with the heart, an abnormal pattern or rhythm—a dysrhythmia—may develop.
Recent research has strongly suggested a central role for abnormal gut sensitivity. According to this view, motility in the gut is normal. However, the nerve endings in the lining of the small and large intestines are unusually sensitive and will react abnormally to even ordinary events such as eating. For example, when ingested food reaches the bowel, the gut wall expands (or distends), causing the nerves to trigger exaggerated patterns of muscular activity. As a result, sometimes, a meal may be followed almost immediately by cramps, and soon after by a bowel movement. Other stimuli that can cause this over-reacting include stressful events, taking certain medications, drinking milk or swallowing too much air.
In any person with irritable bowel syndrome, it is difficult to pin down the cause because each time, the underlying disorder, or combination of contributing disorders, will probably be different. Thus, there is no specific test you can take that will tell whether or not you have IBS — and no procedure that will allow the physician to see what is wrong. In technical language, that means IBS is a functional disorder.
Nevertheless, your physician will frequently order tests, because your symptoms might suggest the presence of another, more serious disease. He or she will be particularly alert to this possibility if you have rectal bleeding, weight loss, or severe, persistent pain. After analyzing the results of appropriate tests, the physician will be able to reassure you, for example, that you do not have cancer.
What to Do about It
Even though we do not fully understand the causes of irritable bowel syndrome, dietary recommendations and techniques for reducing stress, along with the use of medications for specific symptoms, have been shown to work for a substantial number of people. Both diet and stress can be managed quite well. For example, adding more fiber, drinking lots of water, and following a moderate exercise program may do the trick for some. Others may need to keep a food diary for a few days to target problem foods, or learn to deal with stress situations through counseling.
Diet
Fat seems to be a major offender in exacerbating IBS, because in any form it is a strong stimulus of colonic contractions. So, foods such as cream, cheese, vegetable oils, shortening of any kind, avocados, whipped toppings, and meat will need a reevaluation. It's not necessary to eliminate any of them altogether. However, it is helpful to know exactly how much of each item you're eating. With that information in hand, you can begin to make some small modifications. Start by reducing portion sizes, using less rich sauces with main dishes, and having more high-fiber foods at meals and as snacks.
Chocolate, caffeine, alcohol, and milk products are also frequent offenders. Yogurt and other cultured products may not give any distress at all.
For a while, you'll have to keep a journal noting the foods that seem to cause the most problems. The latest research indicates that fructose (a sugar found in fruit) and sorbitol (an artificial sweetener) may aggravate IBS symptoms. That may be why apple, grape, and pear juices are linked with diarrhea and abdominal pain. Excessive intake of magnesium-containing antacids also can cause diarrhea.
In many people with IBS who predominantly have constipation, dietary fiber seems to offer relief. Increase your fiber intake gradually, and eat just enough so that you have a soft and easily passed bowel movement. Fruits, vegetables, whole-grain cereals and breads, lentils, and beans all are good sources of dietary fiber. Six to 11 servings of breads, cereals, and grains; 3 to 5 servings of vegetables; and 2 to 4 servings of fruits are the recommendations in the Dietary Guidelines for Americans and the Food Guide Pyramid. In addition, you might want to include about three tablespoons of bran each day with meals. Start with one tablespoon of bran once or twice a day, and work your way up from there.
Reduce or eliminate any foods that you already know cause distress for you. Beans, for instance, are usually not well tolerated by people with IBS. Other gas-producing foods, such as cabbage or grapes, also may be a problem.
Strange as it may seem, high-fiber diets can also help when diarrhea is the major symptom. The basic water-holding ability of fiber helps to absorb excess fluids and also to increase the bulk of the stool. Those two actions are beneficial in regulating colonic motility. That regulation, or adjustment, means a stabilizing effect for both constipation and diarrhea.

On the other hand, there are a few individuals in whom fiber may intensify constipation or diarrhea. For them, high-fiber foods should be eliminated from the diet. It's a good idea to talk to your doctor or dietitian first. Even if you're not one of these individuals, it's possible you may

have added too much fiber too soon; your system may not have yet had the opportunity to adjust to the presence of extra fiber.
Cramping and diarrhea can be brought on by large meals. So, try to eat smaller meals throughout the day, or reduce the total amount you eat. In addition, select foods that are low in fat and high in fiber. While you're at it, learn to chew your food thoroughly, and allow enough time to eat your meals slowly and in a relaxed way.
Make sure to drink plenty of water as you begin to increase your fiber intake. Six to 8 glasses of water a day - probably more than you're drinking now - should be the goal. The extra fluid will also keep you well hydrated and feeling better throughout the day. You'll want to avoid carbonated water (or other drinks), especially with meals. These can produce "gas" and lead to discomfort.
In fact, you may even want to avoid sipping plain water during meals because it facilitates the swallowing of air which can increase gas. Make a habit of drinking water in the early and mid mornings and afternoons.
You may want to identify foods that you suspect you're allergic to or don't tolerate well. In some people, citrus fruits, gluten, eggs, or chocolate may produce reactions. Note, though, that lactose is less often an offender than is commonly believed. And a person with true intolerance can readily find low-lactose dairy products, as well as lactase supplements which will facilitate the digestion of lactose in food.
Stress
Stress whether it be related to business, career, marriage, family, fear of a dreaded disease, or sexual difficulties—seems to increase colonic spasms, especially in people with IBS. A true cause-and-effect relationship has yet to be demonstrated, but the evidence in support of a connection is strong. Certainly, irritable bowel symptoms increase during periods of anxiety, depression, or panic. Fortunately, stress-reducing techniques are available. The bonus is that these methods also can help enhance your daily life.
Biofeedback, hypnosis, meditation, and psychological counseling are the most common stress-reducing techniques to help you cope with IBS. The first is a system that trains patients to monitor and improve - their health by learning to recognize signals from their own bodies. It is also quite helpful in teaching people how to relax. Initially, biofeedback involves the use of equipment that picks up electrical signals in the muscles. It also requires the services of a certified biofeedback therapist, who may also be a physician or a psychotherapist.
Hypnosis is a centuries-old practice that is receiving new attention. The American Medical Association has approved hypnosis training since 1958, and today many health care professionals use this approach to help people with weight problems, cigarette smoking, and chronic stress. Because hypnosis is a state of heightened suggestibility brought on by increased relaxation, people can learn a variety of ways to deal with stress-related behavioral patterns.
Hypnosis seems to hold great potential for those suffering from IBS. One study showed a clinical improvement in 85% of patients under 50 years of age. Be sure you're working with a well-trained, licensed hypnotherapist. Again, he or she may be a physician, a psychologist, or a nurse-practitioner. Most important of all, have a positive attitude. Self-motivation is helpful in changing any behavior.
Other Suggestions
Daily exercise is a great way to reduce stress, and it makes people feel better psychologically as well as physically. Allow enough time for regular bowel movements. Trying to postpone a movement or rushing it will only cause more anxiety. That, in turn, will aggravate your symptoms. Relaxation, as mentioned before, is an important key to the successful management of irritable bowel syndrome.
Sometimes drugs can help provide symptomatic relief. However, know that no one medication will be effective in everyone with IBS. If an individual mostly has diarrhea, his or her physician may recommend loperamide (Imodium), or, on rare occasions cholestyramine (Questran). If severe constipation is the primary problem, consider taking natural vegetable fiber like bran or psyllium. Try food sources of fiber before buying an over-the-counter fiber supplement.
To treat debilitating pain, the physician may consider a tricyclic antidepressant (Elavil). For chronic abdominal pain that presents after meals, part of the treatment may be administration beforehand of an anticholinergic agent (e.g. Levsin) - a drug that inhibits the nerves regulating intestinal contractions.
Some women with constipation predominate IBS may be a candidate for tegaserod (Zelnorm) which can relieve painful bloating and increase frequency of bowel movements.
Finally, bear in mind that treatments for irritable bowel syndrome are personal and depend entirely on the individual. Spend some time identifying what is irritating your individual system. Then develop an approach that can effect lifestyle changes - diet, exercise, and stress reduction - on a gradual basis. Modifications that can be adopted step by step in a comfortable manner are the ones that are most effective and long-lasting.
Reducing Fat
It is helpful to know a few quick tricks that can help keep fat out of your meal while maintaining good flavor.
· Choose low-fat cuts of meat and chicken in the supermarket.
· Try to roast, broil, poach, stir-fry, or microwave when cooking at home. Look for some terms like "roasted" or "broiled" in restaurants instead of ordering foods that are sautéed or fried.
· Use broths, juices, water, and/or wine to steam vegetables, poultry, and fish instead of sautéing in oil.
· In restaurants, ask the server whether the fish or meat is marinated in oil before it is grilled. If it is, request that it be cooked with little or no oil.
· Select low- and nonfat dairy products. Use the higher fat cheeses like gorgonzola, or an aged cheddar in small quantities to perk up the flavor in a grain or pasta dish.
· Invest in a new microwave oven, high quality pressure cooker, or nonstick wok. All of these devices cook food fast and with little fat and oil.
· Cook quantities of rice, beans, and grains; then freeze in small portions (use zip-lock bags or plastic bowls). These foods defrost quickly or they can be tossed (while still frozen) into soups and sauces.
· Puree leftover beans or vegetables with a bit of salt and your favorite herb (basil, perhaps) to use as a tasty replacement for butter or cream cheese.
· Read labels. The new food label format makes it easier than ever to know exactly how much fat is in one portion of that food. Consider how many portions you'll really be eating. However, don't automatically pass up an item if it appears to have a large percentage of fat calories. Consider what else you're eating throughout the day. Balance is the key.
How Much Fat?
The recommendations of the U.S. Dietary Guidelines for Americans and a number of other health organizations are quite consistent. Fat should represent 30 percent, or less, of your total daily calories. For most people that concept doesn't mean too much. However, if you consider that most adults consume between 1,500 and 2,400 calories a day, the range for fat should be 50 to 80 grams for the day. Once you choose your number of total fat grams, then try to keep the amount of saturated fat -the kind that comes from animal products - to a third or less of the total amount. For example, if 60 grams is your total fat allowance, keep saturated fat to 20 grams or less per day.
You can be the judge of how many total grams to have each day. Part of that may depend on how severe your IBS is, and what your weight goals are. A registered dietitian can help you plan a menu that is best suited to your lifestyle and personal needs. There is also some flexibility here. Most dietitians today will have you look at a weekly pattern, rather than one day or one meal. In other words, unless you are suffering intense distress, a little more fat on one day can be balanced out with less the next. This is another situation in which a food diary can come in handy. Keeping a record of several days of normal
eating will give a clearer picture of how much fat you're currently eating. That makes it easier to make any adjustments if they're necessary.
Food labels are quite clear about the number of grams contained in one serving. Just be sure to calculate properly if you're actually eating several servings. There are also a number of nifty little fat-counter books around. They list a wide variety of all the food categories with the amounts of fat in specific items; frequently they include calorie and cholesterol information as well. They're a good way to start getting acquainted with the amount of fat that's in your favorite foods.
lntestinal Gas and Flatulence
People with irritable bowel syndrome are particularly bothered by the pain, discomfort, and embarrassment of "gas." Whether that gas is coming from above the belt or below, it's still a nuisance. Knowing more about gas can help make its management easier. In most cases, it should be possible to reduce its occurrence considerably.
Basically there are three sources of intestinal gas. Every day each one of us produces about 10 liters (or some 10 quarts) of gas. Normally, most of the gas is absorbed through the bowel wall into the
bloodstream. People with irritable bowel syndrome don't produce more gas than others. The discomfort may make it feel the way, but actually the amount of gas produced in people doesn't vary considerably. It probably feels more painful to someone with IBS because that person is more sensitive to normal degrees of abdominal distention and because there may be abnormal intestinal motility.
Room air is another source of gas. Most of the time, too much air is swallowed ("aerophagia") while eating or drinking. Aerophagia may be a nervous habit, related to anxiety. Gulping food, chewing gum, chewing with your mouth open, and drinking carbonated beverages are other means by which too much air gets into the stomach. The result is belching, the most common symptom of gas. Excess air can cause further discomfort if you wear tight clothes or lie down soon after a meal. If the air isn't released through belching, then bloating and abdominal discomfort result.
Gas expelled through the rectum (flatulence) is usually caused by fermentation of food by "friendly" bacteria normally present in the intestine. These bacteria frequently act on indigestible carbohydrates like those found in beans, dried peas, and lentils. Fruits and grains, which are also high in fiber, can have the same effect. Other food sources that may cause flatulence include milk and other dairy products; fructose, a fruit sugar which is used as a sweetener in foods and beverages and which may be incompletely digested; and sorbitol and mannitol, two artificial sweeteners. Flatulence also can be caused by certain medicines like colestipol (Colestid), which is used to lower blood cholesterol levels.
What to Do about It
Diet

Avoid gas-producing foods. Once again, the food diary becomes a handy tool for identifying offending foods. Remember that what bothers one person may not bother another. The quantity of food or beverage ingested may be a factor. For instance, someone may experience pain after eating two cups of beans, yet be fine with a half-cup serving.
For nutrition's sake, don't just randomly eliminate foods from your diet. Take some care to find alternative solutions as well. For instance, if beans are irritating, consider using Beanoâ, a nonprescription product containing alpha-galactosidase, an enzyme which breaks down the carbohydrates in beans that most people find bothersome. Note: this is added to foods as well as swallowed or chewed. Another possible solution for reducing intestinal gas is to soak the beans overnight and discard the soaking water before cooking. Adding fiber slowly to the diet and drinking plenty of water along the way are the best means of avoiding excess flatulence. Though not systematically studied, regular exercise has been reported to aid in relieving or preventing gas.

Other Suggestions

Relaxation techniques may be helpful in reducing the amount of air swallowed if the problem is related to stress. Other remedies include eating fewer hard candies, reducing the amount of carbonated beverages you drink, and even talking less when you eat. Finally, over-the-counter products like simethicone (Mylicon) and simethicone-containing antacid preparations may be effective in breaking-up trapped gas.
Possible Gas Producing Foods:
The real list of problem foods is potentially endless because everyone's body responds to food differently. Here's a list of the foods that most commonly cause distress.
Fruits: Misc.:
Apples (raw), Carbonated beverages
Apple juice
Avocado, Chewing gum
Bananas, Hard candy
Cantaloupe, Nuts
Honeydew, Mannitol and Sorbitol
Grapes
Raisins
Watermelon Fats and high fat foods
Rich sauces and gravies
Vegetables:
Beans (kidney, lima, navy) Onions
Broccoli, Split peas
Brussels sprouts, Lentils
Cabbage Peppers, green
Cauliflower, Radishes
Corn, Scallions
Cucumbers, Shallots
Leeks, Soybeans
Cereals and Grains:
Bran Cereals
Excessive quantities of wheat products

Pancreatitis
The pancreas is an elongated pear-shaped organ about 6 inches in length, somewhat wider on the right side and narrower on the left. It consists of four anatomic regions: head, uncinate process, body and tail. Located deep within the body, it stretches across the upper abdomen, situated behind the stomach and in front of the spine. Acute pancreatitis is a sudden inflammation of the organ that results in impaired function. Severe cases can effect functioning of other organs systems as well.

FUNCTION OF PANCREAS

The pancreas is made up of two different major cell types, each with their own function: exocrine cells manufacture digestive enzymes responsible for proper digestion of food; and endocrine cells responsible for manufacturing the hormone insulin to regulate blood sugar.

• Digestive Enzymes are potent chemicals that break down our food into its core elements. (For example, a large protein molecule from a hamburger is broken down into small amino acid molecules.) To prevent the pancreas from digesting itself, these enzymes are stored in an inactivated form. When you eat, the pancreas releases these inactivated enzymes into a system of tiny drainage ducts that come together like branches of a tree and form the main pancreatic duct. Draining from left to right, the main pancreatic duct joins the common bile duct which drains bile from the liver and gallbladder. Together they empty their contents into the intestine through a small nipple in the wall of the duodenum called the papilla, or Ampulla of Vater. Once in the duodenum, the pancreatic enzymes are activated and begin the process of digestion.
  
• Insulin is a hormone manufactured by the pancreas islet cells that regulates blood sugar. When you eat, the starches and complex sugars in your food are broken down into simple sugar, glucose, and absorbed into your bloodstream. This raises the level of sugar in your blood. Acting like a thermostat, pancreas senses this rise in blood sugar. In response, it secretes insulin which carries sugar molecules out of the blood stream and into the cells of body where it is used for energy, or stored as fat.

CAUSES OF ACUTE PANCREATITIS

1. Gallstones - Sometimes, a gallstone will be extruded out of the gallbladder and travel down the bile duct. If the stone is too big to pass, it will often become lodged at the papilla. This blockage causes a backup of pressure into the pancreatic ducts. This backup unintentionally activates the digestive enzymes within the pancreas itself. This is a big problem since the pancreas then begins to digest itself which releases even more enzymes, starting a chain reaction of self-destruction.

2. Alcohol – Alcohol is a direct toxin (poison) to the pancreas. Chronic alcohol abuse or binge drinking is directly associated with triggering attacks of acute pancreatitis.

Other less common conditions that may cause acute pancreatitis include hereditary pancreatitis, blunt force abdominal trauma (like hitting the steering wheel during a car accident), post-ERCP pancreatitis, high blood calcium from overactive parathyroind gland or kidney failure, and high blood fat (triglyceride) levels. Certain medications may occasionally cause pancreatitis. These may include DDI (dideoxycytosine), DDC (dideoxyinosine), (Imuran) azathioprine, (Purinethol) 6-mercaptopurine, tetracycline, Depakene (valproic acid), Tylenol (acetaminophen), and others. Pancreatitis is associated with certain connective-tissue disorders such as Lupus (SLE), polyarteritis nodosa, and sarcoidosis. Infectious causes including viruses such as mumps, rubella, cytomegalovirus (CMV), HIV-AIDS, and others. Some bacteria can cause pancreatitis such as Campylobacter and Legionella. Approximately 15% of cases, the cause of acute pancreatitis is unknown, so-called idiopathic acute pancreatitis.

SYMPTOMS

Typical symptoms include sudden onset of severe pain in the upper mid-abdomen. The pain is a constant and may radiate to the back. Some patients have symptoms of nausea, vomiting and fever. Often, the pain is temporarily relieved by sitting up and bending forward - a characteristic of pancreatic pain.

DIAGNOSIS

1. Blood tests measuring the level of amylase and lipase. These are the normal enzymes that aid in the digestion of food in the intestine. They are made in the pancreas, secreted into the pancreatic ducts, and transported through the ducts to the intestine. When there is inflammation of the pancreas or blockage of the pancreatic ducts, lipase and amylase seep out of the pancreas and into the bloodstream.

• Amylase - On average, during uncomplicated cases, the serum amylase level starts increasing from two to 12 hours after the onset of symptoms and peaks at 12 to 72 hours. It usually returns to normal within one week. Rarely both amylase and lipase levels may be normal in a patient with CT-proved pancreatitis.
  
• Lipase - An elevated lipase level is a bit more specific for pancreatitis since amylase is also produced in other organs of the body like the salivary glands. Lipase is only produced in the pancreas. Lipase levels increase within four to eight hours of the onset of clinical symptoms and peak at about 24 hours. Levels decrease within eight to 14 days.

• Liver enzymes – AST, ALT, bilirubin, alkaline phosphatase, GGTP) are often elevated as well.

Radiologic tests

• Ultrasound – Is often the initial radiologic test performed in work-up of suspected pancreatitis. Ultrasound is noninvasive, relatively inexpensive and may be performed at the bedside. The sensitivity of this study in detecting pancreatitis is good, but the pancreas is sometimes obscured secondary to bowel gas.
  
• Computed Tomography (CT scan) - The contrast-enhanced CT scan provides the best imaging of the pancreas and surrounding structures. CT scanning is helpful in establishing the diagnosis and in assessing complications related to acute pancreatitis which may include enlargement of the pancreas, fat necrosis, abscess, or a pseudocyst.
  

• Endoscopic Retrograde Cholangiopancreatography (ERCP) - ERCP has a limited role in management of acute pancreatitis since the test itself may cause pancreatitis. ERCP is sometimes used in patients with severe disease who are suspected of having an obstruction and biliary infection (cholangitis) due to impacted gallstones. ERCP can be used to either remove the stones or temporarily bypass the obstruction with a plastic stent.. The risks of performing ERCP include precipitating an acute episode of pancreatitis, introducing infection and causing hemorrhage and perforation.

TREATMENT

The treatment of pancreatitis may be conservative or aggressive depending upon the severity of inflammation and the development of complications. Since there is no currently proven medication for acute pancreatitis, treatment is mostly supportive. Most patients are hospitalized and given IV fluids. Since eating stimulates the pancreas, food is withheld to "rest" the pancreas. Medications are given to control pain. The role of antibiotics is controversial. But, if infection is suspected, IV antibiotics are added. In prolonged cases, aggressive IV nutritional support is also necessary.

The risk of abdominal surgery is high in any seriously ill patient. Surgery is only performed as a last resort in acute pancreatitis. If there is suspicion of an uncontrolled abscess or severe necrosis (death) of pancreatic and surrounding tissue, a CT-guided fine-needle aspiration may be done to make the diagnosis. If dead tissue or active infection is found, surgery may be necessary to remove the dead tissue and drain the infection. If gallstones are found to be the cause of acute pancreatitis, it is best to have the gallbladder removed once the acute attack has resolved.

COMPLICATIONS

Acute pancreatitis is a serious disease. About 25% percent of patients with severe acute pancreatitis develop complications such as necrosis, multiorgan failure (lungs, kidney, or heart), abscess, or pseudoscyst formation. Unfortunately, the serum amylase level and the lipase level are not specific enough measures of disease activity to predict these complications.

• An abscess is an infected pocket of pus within the pancreas and is usually seen in the most severe cases. If antibiotics don't clear the infection up, the abscess may need to be drained surgically or by a needle that is guided by a CT scan x-ray.
  
• A pseudocyst of the pancreas is a collection of sterile fluid. Pseudocysts occur within a month after the acute episode in about in about one case in six. They sometimes disappear on their own, but can also require surgical or CT scan guided drainage.

PROGNOSIS

Most patients (85%) recover fully from acute pancreatitis within a week or two and do not experience recurrence, if the cause is removed. Recurrences are common with continued alcohol abuse. However, in some cases, life-threatening complications develop such as necrosis, infection, liver, heart, or kidney impairment. The mortality rate is high when these complications are present.

Ulcerative Colitis
ULCERATIVE COLITIS - Ulcerative colitis is a chronic, recurring disease of the large bowel, or colon. The colon is the 5 to 6 foot segment of intestine that begins in the right-lower abdomen, extends upward and then across to the left side, and downward to the rectum. It dehydrates the liquid stool that enters it and stores the formed stool until it is voluntarily evacuated.
When ulcerative colitis affects the colon, inflammation and ulcers, or sores, form in the lining of the colon. The disease may involve the entire colon (pancolitis), only the rectum (ulcerative proctitis) or, more commonly, some area between the two.
Causes
The cause of ulcerative colitis is unknown. Some experts believe there may be a defect in the immune system in which the body's antibodies actually injure the colon. Others speculate that an unidentified microorganism or germ is responsible for the disease. It is also possible that a combination of factors may be involved in the cause.
RISK FACTORS
The disorder can occur in both sexes, all races and all age groups. However, it is a disease that usually begins in young people.
Symptoms
The disorder typically begins gradually, with crampy abdominal pain and diarrhea that is sometimes bloody. In more severe cases, diarrhea is very severe and frequent. Loss of appetite and weight loss occur, and the patient becomes weak and very sick. When the disease is localized to the rectum, the symptoms are rectal urgency, bleeding and passage of small amounts of bloody stool. Usually the symptoms tend to come and go, and there may be long periods without any at all. Inevitably, they recur.
Diagnosis
Diagnosis of ulcerative colitis can be suspected from the symptoms. Initially, certain blood and stool tests are performed to rule out an infection that mimics the disorder. A visual examination of the lining of the rectum and lower colon (sigmoidoscopy) or the entire colon (colonoscopy) is required. This exam typically reveals a characteristic pattern. Small, painless biopsies are taken which also show certain features of ulcerative colitis.
You'll need periodic checkups even if you feel fine. As the inflammation caused by ulcerative colitis is reduced, you will feel less rectal discomfort and urgency to defecate. Your rectal bleeding will also diminish.
Though it may seem intrusive or embarrassing, keep in mind that visual examination of the rectum is necessary to verify that your disease is indeed getting better. Furthermore, because ulcerative colitis is generally a persistent disease, your doctor will probably want to examine you periodically with a sigmoidoscope, even when you have no apparent symptoms. (Another reason is that symptoms often improve before medication has completely healed the tissue.)
In the event your ulcerative colitis returns following a remission, your doctor will re-evaluate you to determine the extent of disease and to find out if your condition is being complicated by infection, drug reaction or some other factor. When drug treatment is resumed, your doctor probably will prescribe the same agent you were treated with previously. If the drug you are using doesn't seem to be working, your doctor will discuss alternate drug treatment with you.
Complications
Most patients with this disease respond well to treatment and go about their lives with few interruptions. However, some attacks may be quite severe, requiring a period of bowel rest, hospitalization and intravenous treatment. In rare cases, emergency surgery is required. The disease can affect nutrition causing poor growth during childhood and adolescence. Liver, skin, eye or joint (arthritis) problems occasionally occur, even before the bowel symptoms develop. Other problems can include narrowing and partial blocking of the ducts which carry bile from the liver to the intestine (Primary Sclerosing Cholangitis). Fortunately, there is much that can be done about all of these complications. In long-standing ulcerative colitis, the major concern is colon cancer. The risk of developing colon cancer increases significantly when the disorder begins in childhood, has been present for 8 to 10 years, or when there is a family history of colon cancer. In these situations, it is particularly important to perform regular and thorough surveillance of the colon, even when there are no symptoms. Analysis of colon biopsies performed during colonoscopy can often predict who will develop colon cancer. In these cases, preventive surgery is recommended.
Treatment
You can work and play as usual. Though it can be troublesome, ulcerative colitis shouldn't debilitate or disable you. In fact, you should be able to conduct your recreational and career activities with little difficulty - in short, be as active as you feel like being.
Remember, though, that living with ulcerative colitis requires vigilance. You'll probably be on some form of medication for long periods of time, and regular medical checkups may also be required. To control the disease effectively it is important that you adhere to the medication schedule that your doctor gives you. Also, it is equally important that you inform your doctor immediately if any other symptoms should appear—symptoms such as rectal bleeding, discomfort or frequent urges to defecate.
There are several types of medical treatments available:
1. Cortisone, Steroids, Prednisone—These powerful drugs usually provide highly effective results. A high dose is often used initially to bring the disorder under control. Then the drug is tapered to low, maintenance doses, even to an alternating daily schedule.
These medications are given by pill, enema or intravenously during an acute attack. In time, the physician will usually try to discontinue these drugs because of potential adverse side effects.
2. Other Anti-inflammatory Drugs—There are increasing numbers of these drugs available. They can be given by pill or enema. The generic and (trade) names of these drugs are sulfasalazine (Azulfidine), olsalazine (Dipentum), and mesalamine (Asacol, Pentasa and Rowasa).
3. Immune System Suppressors—An overactive immune system is probably important in causing ulcerative colitis. Certain drugs such as azathioprine (Imuran), 6-MP (Purinethol) and cyclosporine (Sandimmune) suppress the immune system and at times are effective.
You should also remember that meaningful advances are being made in treating all forms of inflammatory bowel disease; over the past decade, we have added to our understanding of what ulcerative colitis is and how it works. Ongoing research insures that new discoveries about the causes and course of this disease will be made and that newer treatments will be developed. But for now, keep in mind that ulcerative colitis is relatively easy to cope with—provided you maintain the will and determination to keep it under control. And remember, too, that taking your medication as directed is also a vital part of controlling ulcerative colitis; follow your doctor's instructions carefully.

Diet and Emotions
You don't have to change the way you eat. There is no evidence that specific diets will make your colitis better—or worse. But there are certain things you can do that will make your disease easier to live with. For instance, foods that are high in fiber may prove useful if you are frequently experiencing painful bowel movements or urgency to defecate. If your symptoms should include constant diarrhea, a low-fiber diet that includes soft, bland foods can help, but only temporarily. In addition, some colitis patients are unable to properly digest lactose, a sugar found in milk and many milk products. This condition may cause cramps, pain, gas, diarrhea and a bloated feeling in the stomach. If you fall into this category, a lactose-free diet may be beneficial. Your physician can advise you on this.
Generally, the patient is advised to eat a healthy, well-balanced diet with adequate protein and calories. A multiple vitamin and iron supplement is often recommended.
Keep a positive mental attitude. Stress and anxiety may aggravate symptoms of the disorder, but are not believed to cause it or make it worse. The same holds true for menstrual periods in women. It is also normal to feel depressed at times about your disease or because no one seems to understand how you feel. You should discuss such thoughts with your doctor or family members.
It may also be helpful to talk to someone else who has ulcerative colitis; the Crohn's and Colitis Foundation of America (CCFA) may be able to refer you to other colitis patients in your vicinity. Check your telephone directory for the CCFA chapter in your area, or ask a doctor. Surgery For patients with long-standing disease that is difficult or impossible to control with medicine, surgery is a welcomed option. In these rare cases, the patient's lifestyle and general health have been significantly affected. Surgical removal of the colon cures the disease and returns good health and a normal lifestyle to the patient. In the past a bag, or ileostomy, was required after surgery. Newer operations may avoid the need for an ileostomy. In this operation, a reservoir is created by the small intestine just above the rectum.